"hospital_name","last_updated_on","version","location_name","hospital_address","type_2_npi","license_number|CA","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.","attester_name"
"California Pacific Medical Center- Van Ness Campus","2026-04-01","3.0.0","California Pacific Medical Center- Van Ness Campus","1101 Van Ness Avenue, San Francisco, CA 94109","1104984392|1689732885|1740348929|1831257013|1871731810|1902964109","220000197","true","Bruce Preston"
"description","code|1","code|1|type","code|2","code|2|type","code|3","code|3|type","code|4","code|4|type","billing_class","setting","drug_unit_of_measurement","drug_type_of_measurement","modifiers","standard_charge|gross","standard_charge|discounted_cash","payer_name","plan_name","standard_charge|negotiated_dollar","standard_charge|negotiated_percentage","standard_charge|negotiated_algorithm","median_amount","10th_percentile","90th_percentile","count","standard_charge|methodology","standard_charge|min","standard_charge|max","additional_generic_notes"
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","84126.9","84126.9","84126.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","57816.06","57816.06","57816.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","5780.02","5780.02","5780.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Iodine i-123 ioflupane","0781","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","450.65","450.65","450.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","44280.04","44280.04","44280.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pmkr, dual, leadless","2046","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","81179.59","81179.59","81179.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","28249.69","28249.69","28249.69","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cath coronary drug-delivery","2050","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","10518","10518","10518","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","2384.76","2384.76","2384.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","9720.64","4851.44","9794.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1838.89","1798.72","2410.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","5499.39","5499.39","5499.39","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","8193.47","8193.47","14684.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","4715","4715","7721.11","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3364.67","3364.67","3364.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","4405","4020","13681.81","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","9823.76","9823.76","9823.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tissue marker, detectable","2055","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","225.75","155.25","324.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","324.75","324.75","325.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","169.92","122.13","256.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","222.74","130.98","321.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","189.16","185.46","189.16","51","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","106.02","106.02","106.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","185.46","185.46","185.46","104","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","159.18","159.18","606","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","229.5","229.5","383.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","137.25","137.25","137.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","9194.24","9194.24","9194.24","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","329.84","329.84","329.84","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinic Visits and Related Services","5012","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","185.46","185.46","185.46","53","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","1067.08","1067.08","1067.08","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","439.1","439.1","439.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","571","571","571","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","428.25","428.25","428.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1373.84","1074.75","1620.75","13","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1564.5","1564.5","1564.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","1096.25","1060.42","2538.94","22","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","234.25","234.25","234.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","854.32","854.32","854.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","1134.3","1041.66","2730","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","858.37","858.37","858.37","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","1522.97","1522.97","1522.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","229.19","229.19","229.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","230.09","230.09","230.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","1074.75","1074.75","2192.25","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","1585.36","1089.08","4166.32","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Type A ED Visits","5022","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","230.69","228.89","552.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2948.25","2172","5481.75","30","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","3792.75","3792.75","6204.38","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2614.88","1852.01","5627.17","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","3132.42","2157.1","5288.78","105","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","408.23","398.46","927.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","3337.03","2250.44","4814.76","16","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","552.79","399.76","849.6","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","3455.12","2227.02","7396.94","29","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","2528.31","2271.46","2920.62","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","395.93","395.93","395.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","2985.34","2985.34","2985.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","2721.03","2172","4398","69","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","5360.28","5360.28","5360.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3125.12","2200.96","5615.87","45","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Type A ED Visits","5023","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","535.38","399.46","747.32","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","6473.25","4010.25","14361.07","94","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","10927.5","9103.07","13943.57","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","4665.72","3294.56","11258.64","17","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","5866.04","3815.72","13587.37","211","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","898.64","614.57","1151.04","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","6023.25","3306.48","11479.64","40","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","917.27","614.07","1497.89","52","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","6100","4003.71","13891.31","66","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","8378.82","4064.81","11080.44","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","401.26","401.26","401.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","1429.89","1429.89","1429.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","5691.75","3725.25","10862.63","118","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","5845.92","4518.2","9607.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1488.33","1488.33","1488.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","6559.56","4311.12","13367.43","112","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Type A ED Visits","5024","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","880.27","613.78","1663.81","26","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","8008.1","2429.25","15216.75","32","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","16321.5","9593.25","20011.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","6929.2","5623.88","14012.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","8218.44","6259.29","16368.06","86","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1407.96","901.73","2259.61","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","11595.07","7199.35","17334.44","14","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1478.06","1036.61","2627.18","39","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","9957.48","7122.14","20280.59","33","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","12326.98","9378.12","12605.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3813.02","3813.02","3813.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","6175.03","6175.03","18486.85","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","8917.13","6465.75","19819.64","41","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","27442.08","11774.68","32430.7","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1338.5","1338.5","1338.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","10734.24","6643.92","18119.92","42","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Type A ED Visits","5025","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1398.93","884.08","3931.64","28","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","9001.5","9001.5","9001.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","35225.33","35225.33","35225.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","34759.93","34759.93","34759.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1365.59","1365.59","1365.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","15477.15","15477.15","15477.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","33548.4","33548.4","34133.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Critical Care","5041","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1863.21","1863.21","1863.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","2028.22","2028.22","5258.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","1585.36","1585.36","1585.36","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Skin Procedures","5051","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3976.32","3976.32","3976.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Skin Procedures","5052","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","10977.1","10977.1","10977.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8344.93","8344.93","8344.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","3723","3723","6515.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","3138.34","2513.78","5239.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1036.97","1036.97","1036.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1014.51","1014.51","1132.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","3261.33","3261.33","3261.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","2540.36","2540.36","3417","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","3587.89","3587.89","3587.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","3863.25","3191","18725.79","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3397","3223.16","4633.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3234","3234","3234","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","5138","5138","8152.36","34","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","7707","5138","9655.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","6143.03","2477.39","8848.83","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","1446.21","695.81","2196.81","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","7315.57","4859.36","10471.2","71","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2449.3","2449.3","2454.3","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","7072.5","4715","9656.5","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2333.61","2331.61","2469.32","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","6156.38","5342","10943","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","5342","5342","10684","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","4405","4405","8187.53","25","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","6080.49","6080.49","6080.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","416.04","416.04","416.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","717.33","717.33","717.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","4747","4747","9494","30","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2331.61","2331.61","2455.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","8645.94","8645.94","8645.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","14544.15","14544.15","14544.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4123.09","4123.09","4123.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","562.83","562.83","562.83","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","21615.51","21615.51","21615.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","17381.19","17381.19","17381.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","57387.03","57387.03","57387.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","5704.66","5704.66","5704.66","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","1585.36","1585.36","1585.36","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Musculoskeletal Procedures","5111","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","5889","5889","5889","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","3910.9","3910.9","3910.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","13349.07","13349.07","13349.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","5513.25","5513.25","5513.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","11975.32","11975.32","11975.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","27322.15","27322.15","27322.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","10282.2","10282.2","10282.69","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","43461.66","43461.66","43461.66","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","10280.2","10280.2","10280.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","3406.5","3406.5","3406.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","19830.23","19830.23","19830.23","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","17860.85","17860.85","20139.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5433.91","5305.71","10202.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","9938.21","9938.21","9938.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","23339.86","23339.86","23339.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5307.71","5307.71","5307.71","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","31606.08","31606.08","31606.08","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Airway Endoscopy","5154","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","29745.15","29745.15","29745.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","15496","15496","15496","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","12049.94","12049.94","12049.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","21550.73","21550.73","21550.73","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","34829","34829","34829","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Airway Endoscopy","5155","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","4297","4297","4297","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","12165.75","12165.75","12165.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","626.54","626.54","626.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","6597","6597","7344.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","15441.4","15441.4","15441.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","11800","11800","11800","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","6241","6241","6241","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","20072","20072","20072","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 ENT Procedures","5164","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","21035.54","21035.54","37087.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","39184.25","18746.66","52989.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","4999","4999","4999","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","41250.18","41250.18","41250.18","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","50418.42","50418.42","50418.42","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8514.94","8514.94","8514.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","41620.71","41620.71","41620.71","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","65252.42","65252.42","65252.42","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 ENT Procedures","5165","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8514.94","8514.94","8514.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","3577.7","3577.7","7289.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1067.29","1067.29","1067.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","891.71","891.71","891.71","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","891.06","891.06","891.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Vascular Procedures","5181","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","6459.62","6459.62","6459.62","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","6541.96","6477.09","21861.91","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","6599.93","6599.93","6599.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","6557.89","6557.89","6557.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","6534.06","6534.06","6534.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","8487.1","8487.1","8487.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","2169.55","2169.55","2169.55","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2235.48","2235.48","2235.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Vascular Procedures","5182","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","15970","15970","15970","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","9706.1","8543.92","10216.44","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","559.75","223.22","1428.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","15864.75","11270.22","16615.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4529.41","4529.41","4529.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4531.41","4531.41","4531.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","24552.26","24552.26","24552.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","14650","12498.08","19725","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","16601","16601","16601","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","13509.47","12290.19","14220.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","34762.57","34762.57","34762.57","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Vascular Procedures","5183","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7661.01","7661.01","7661.01","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","25563.65","25563.65","25563.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","30480.43","30480.43","30480.43","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","13913.63","13913.63","13913.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Vascular Procedures","5184","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7779.09","7779.09","7779.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","35670.98","35670.98","35670.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","46806.49","46806.49","46806.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","709.01","709.01","1317.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","38088.65","22831.67","47697.42","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5684.24","4628.58","8208.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4630.58","4563.17","8206.79","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","54458.93","54458.93","54458.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","27682.72","27682.72","27682.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","46483.49","46483.49","46483.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","40161.92","40161.92","40161.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","801.48","801.48","801.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","38119.25","38119.25","38119.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Endovascular Procedures","5191","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4628.58","4628.58","4628.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","2608.21","2608.21","2608.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8206.09","8206.09","8206.79","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","305.47","305.47","305.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","12014.25","12014.25","12014.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Endovascular Procedures","5192","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","199.5","199.5","199.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","81591.05","81591.05","81591.05","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","37418.1","37418.1","37418.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","16319.67","16319.67","16319.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2921.5","2921.5","2921.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","66839.07","66839.07","66839.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","107807.72","107807.72","107807.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","16321.67","16321.67","24885.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","92687.07","92687.07","92687.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1605.15","1605.15","1605.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","24963.1","24963.1","24963.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Endovascular Procedures","5193","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","61371.74","60821.37","100363.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","35773.93","35773.93","35773.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","64091.77","64091.77","88020.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","10921.67","10921.67","10921.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","20869.5","20869.5","20869.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1809.77","1809.77","1809.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","48142.68","41376.7","130143.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","147703.95","22455.13","189832.38","18","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","35305.75","35303.59","36156.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","5963.43","5963.43","5963.43","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","35305.25","35303.25","35305.25","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","119396.78","119396.78","119689.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","125185.02","125185.02","129783.66","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","144188.96","144188.96","144188.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","152533.54","152533.54","152533.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","145526.95","116775.16","161203.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","35305.25","35305.25","35322.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","30652.11","30652.11","30652.11","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","51245.88","51245.88","51245.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","15965.8","15965.8","15965.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","15415.88","15415.88","15415.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","11909.76","11909.76","11909.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","41366.26","41366.26","41366.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","31479.09","31479.09","31479.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","27444.38","27444.38","27444.38","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","15062.15","15062.15","15062.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","6662.16","6662.16","6662.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","15060.15","15060.15","15060.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","139628.33","139628.33","139628.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","27447.88","27447.88","27447.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","8171.56","8171.56","8171.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","101389.6","101389.6","101389.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","249775.73","249775.73","249775.73","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","9114.57","9114.57","9114.57","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","3846.75","3846.75","3846.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2436","2436","5528.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2436","2436","2436","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","8003.29","3079.74","9989.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","552.7","440.46","620.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","2767","2767","15117.93","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1651.42","1376.17","5866.57","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1351.2","1351.2","2668.77","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","8921.89","2636","26990.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","7430","6366.17","12489.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","4911","2978","4960.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","12671.56","12671.56","12671.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","4771.96","2806","16202.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Upper GI Procedures","5301","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2231.49","2231.49","2231.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","12529.46","5863.67","13719.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2436","2436","2436","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2097","2097","2097","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","1060.13","1060.13","1060.13","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","5655.07","2767","20678.46","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2734.87","2729.87","5474.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","7831.07","3905.74","10704.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2731.87","2729.87","2731.87","17","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","12274.52","5398.36","21717.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","7002.54","7002.54","7002.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","8791.89","8791.89","8791.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","13849.61","13849.61","13849.61","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","6","6","6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2729.87","2729.87","2729.87","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","2022.12","2022.12","2022.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","2806","2806","12782.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Upper GI Procedures","5302","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2731.87","2729.87","5474.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","9577.53","9577.53","9577.53","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","38010.77","38010.77","38010.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","12805.88","8731.1","18485.33","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5478.45","5478.45","5478.45","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","24026.12","24026.12","24026.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","11347.33","11347.33","11347.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5476.92","5476.92","5476.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","11529.44","11529.44","11529.44","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","21671.86","21671.86","21671.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Upper GI Procedures","5303","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2699","2699","8761.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2699","2699","2699","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2217","2217","2217","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","403.81","403.81","403.81","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","2925","2925","12502.14","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1338.24","1312.41","1338.24","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1311.99","1311.99","1311.99","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","2896","2896","5844.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","3302","3302","30469.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3113","3113","3166.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Lower GI Procedures","5311","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1314","1314","1314","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2699","2699","4048.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","4048.5","4048.5","4657.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2217","2217","2217","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","455.67","398.96","894.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","2925","2925","2925","23","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1737.75","849.24","3297.53","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","3623.54","2557","4496.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2333.89","1696.75","3222.23","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","4214","2896","9030.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","2896","2896","2896","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","4791","4791","4791","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","5394","5394","5394","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1054.41","1054.41","1054.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3113","3113","3113","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Lower GI Procedures","5312","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1696.76","1696.76","3217.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","9893.54","9893.54","9893.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","13724.66","13724.66","13724.66","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","11327.13","8229.73","14539.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","4798","4798","4798","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","15306.37","15306.37","15306.37","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","27359.27","27359.27","27359.27","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Lower GI Procedures","5313","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","3011.15","3011.15","18856.3","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","2825.31","2825.31","2825.31","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","40771.27","22846.32","74696.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","49098.68","49098.68","49098.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","21111.47","21111.47","21111.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8568.41","8568.41","8568.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","21303.91","20926","42859.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","20374.34","20374.34","20374.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8391.59","8391.59","8391.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","24189.96","24189.96","24189.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complex GI Procedures","5331","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","9858.79","9858.79","9858.79","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","18632.47","18632.47","18632.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5201.21","5201.21","5201.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","17153.35","17153.35","17153.35","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","25893.41","25893.41","25893.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5080.5","5080.5","5080.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","20014.28","20014.28","20014.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","888.9","888.9","888.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","12978.67","12902","37754.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","36104.74","36104.74","58910.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","24451.02","20268.07","36549.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","80647.6","80647.6","80647.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","36555.49","12811","48459.76","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8599.12","8599.12","8599.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","11579","11579","25697.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8397.94","8397.94","8398.43","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","35255.87","35255.87","86097.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","37426.76","19531.74","46197.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","3447.32","3447.32","3447.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1685.32","1685.32","1685.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","2898.2","2898.2","2898.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","35393.31","13858","49908.35","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","14982.28","14982.28","14982.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","44777.35","44777.35","44777.35","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","33125.31","33125.31","65060.18","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","1907.32","1907.32","1907.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","26324.47","12811","152575.38","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","52261.78","52261.78","52261.78","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","37730","37730","37730","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","42754","42754","42754","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","14986.28","14986.28","14986.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","153095.24","153095.24","153095.24","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","46347.4","46347.4","46347.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","84.53","84.53","217","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","37761.79","37761.79","37761.79","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","52470","52470","52470","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","2860.3","2860.3","2860.3","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","748.68","748.68","748.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2900.74","2900.74","2900.74","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","13277.01","13277.01","13277.01","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","9804.29","9804.29","9804.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Urology and Related Services","5373","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","15186.14","15186.14","15186.14","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","19478.35","18672.82","21333.66","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","7217","7217","7217","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","14942.2","14942.2","14942.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","19261","19261","19261","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","865.68","865.68","865.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","6983","6983","6983","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Urology and Related Services","5374","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","9852.72","7957.89","13307.13","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Urology and Related Services","5375","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1008.93","1008.93","1008.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dialysis","5401","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1552.5","1035","2137.5","71","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1552.5","1552.5","1552.5","25","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","74.67","74.67","102.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","1531.8","1531.8","1630.22","103","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","1770","1770","1770","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","1239.93","1239.93","1239.93","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","1591.83","1591.83","1591.83","42","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","369.25","369.25","369.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","1552.5","906","1552.5","68","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","95","95","95","38","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","1573.2","918.08","2280","78","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Gynecologic Procedures","5411","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","875","875","875","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","10950","4247.25","18962.54","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","15272","12579.86","17037.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","12863.2","6259","17795.62","37","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4686.07","4686.07","4686.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","610.76","610.76","610.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","6962.32","4744","12304.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","5594","5594","5594","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4577.51","4577.51","4578","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","12177.42","4554.79","22188.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","9283","4191","16754.2","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","5695.94","5695.94","5695.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","670.37","670.37","834.36","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","9972.49","4558.48","17559.15","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Gynecologic Procedures","5414","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4577.87","4577.87","4577.87","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","6274.6","6274.6","6274.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","900.72","900.72","900.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","11215","11215","18232.31","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7275.76","7275.76","7275.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","30371.48","22045.66","51244.64","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","15703.24","15703.24","26251.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","10130","10130","10130","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7106.29","7106.29","7106.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","22941.5","15179.47","25724.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1778.51","1778.51","1778.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","23394.12","23394.12","23394.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 5 Gynecologic Procedures","5415","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","29179.52","29179.52","29179.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","43171.51","43171.51","43171.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","36733.37","36733.37","36733.37","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","10643.86","10643.86","10643.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","3793.98","3793.98","3793.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","436.12","436.12","436.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","5031.96","5031.96","5031.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nerve Injections","5441","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2251.44","2251.44","2251.44","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","5052.72","5052.72","20634.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","19806.12","19806.12","19806.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","4274","4274","4274","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","998.57","998.57","1499.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","4477.92","4477.92","6709.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nerve Injections","5442","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","30859.58","30859.58","30859.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","737.25","737.25","737.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","750.36","727.42","1993.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","893.11","893.11","893.11","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","789.47","789.47","789.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","6481","6418","61285.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","1149.97","1149.97","1149.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","22755.85","22755.85","36392.35","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3282.09","3282.09","3282.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","6351","6351","6351","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","6351","6351","6351","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3284.09","3284.09","3284.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","40126.81","40126.81","40126.81","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3282.09","3282.09","3295.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","199.85","199.85","199.85","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","30522.77","30522.77","30522.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Intraocular Procedures","5491","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3677.59","3674.59","4219.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","32699.99","32699.99","36159.45","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","41184.09","41184.09","41184.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","31984.86","31984.86","31984.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7055.31","7055.31","7055.31","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","32179.37","32179.37","32179.37","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Intraocular Procedures","5492","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7110.2","7110.2","7110.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","52428.16","52428.16","52428.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","45106.52","45106.52","45106.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1521.47","1521.47","1521.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","619.38","619.38","619.38","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","27748.1","27748.1","27748.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","22166.91","22166.91","22166.91","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","15837.1","15837.1","15837.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","59581.19","59581.19","59581.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3359.25","3359.25","3359.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","16371.54","16371.54","16371.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","5869","5869","5869","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3357.46","3357.46","3357.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","924.9","924.9","924.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","35887.63","35887.63","35887.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5428.96","5428.96","5428.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","571.5","355.5","1422","143","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","571.5","276.75","1993.5","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","942.23","228.33","1568.22","31","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","49.35","24.42","289.82","55","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","563.88","301.18","1403.04","385","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","129.77","126.7","129.77","45","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","456.44","283.76","1275.28","104","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","126.7","126.7","297.91","155","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","882.81","297.6","1814.08","109","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","670.5","330","1483.5","228","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","868.68","571.52","1440.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","594.86","594.86","594.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","138.4","58.31","1556.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","299.12","299.12","299.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","77.26","77.26","77.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","736.44","358.72","1503.28","233","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging without Contrast","5521","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","126.71","126.71","297.92","58","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1087.5","518.25","2029.5","193","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1193.25","489","2029.5","46","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","525.1","377.6","1877.38","50","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","110.64","35.48","304.74","57","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","929.44","476.56","2002.44","602","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","156.08","153.03","156.72","76","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","533.11","385.76","1620.89","152","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","153.03","153.03","153.53","301","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","890","429.87","2080.91","174","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","912.8","912.8","912.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","998.25","483","2029.5","268","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","879.32","565.44","2056.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","163.02","73.18","598.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","153.03","153.03","153.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","1011.56","489.44","2056.56","318","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging without Contrast","5522","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","153.03","153.03","153.93","101","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2781","1656.75","5558","28","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2781","2742","3757","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2304","1472.64","4483","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","251.31","176.74","1098.39","23","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","3035","1634.66","4035","77","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","356.26","348.85","356.26","16","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","2160","1555","4093","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","348.35","347.85","501.38","44","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","2756","1955.57","3747.34","22","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","4122.56","4122.56","4122.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","2754","1686","5440","27","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","3222.4","3222.4","3222.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","465.71","172.23","548.91","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","2659","1678.84","3703.48","36","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging without Contrast","5523","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","347.86","347.86","348.76","23","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","3054","2752.5","6176.68","14","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2752.5","1854.84","3277.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","337.1","248.39","600.17","18","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","2715.8","2172.64","6371.74","44","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","808.09","796.03","808.09","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2513.4","2329.32","2750.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","791.03","789.03","942.05","33","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","3338.23","2822.23","7083.93","18","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","2842.85","2198.33","5823","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","10625.43","10625.43","10625.43","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","2752.5","2752.5","6921","29","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","2789.2","2789.2","7903.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","334.22","334.22","334.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","789.03","419.98","792.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3000.48","2789.2","6080.85","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Imaging without Contrast","5524","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","789.43","789.03","3948","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","4020.17","1762.5","6494.6","14","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","7996.6","7996.6","7996.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2173.05","722.16","6194.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","285.52","160.8","463.32","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","4874.39","1793.02","8831.95","44","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","626.16","259.68","641.29","16","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","6234.96","1407.65","6656.66","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","256.68","256.18","626.66","26","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","7931.68","2564.8","9350.32","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","4484.73","1691.17","8778.65","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","8281.5","8281.5","8281.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","336.07","336.07","336.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","996.17","996.17","996.17","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","4811.5","1001.8","8755.9","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Imaging with Contrast","5571","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","257.09","256.19","626.17","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","5237.98","4803.24","9032.03","42","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","4986.32","4984.23","9995.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","4802.13","4093.08","5069.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","398.31","305.66","1165.81","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","5688.39","3853.65","8224.51","95","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","526.35","514.93","526.35","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","3864.05","3237.7","5072.52","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","514.43","514.43","514.43","66","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","4896.44","3434.76","9239.75","29","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","7383.15","7383.15","7383.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","4539.72","4539.72","4539.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","5007.24","3135.32","6824.05","41","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","4895.16","4895.16","4895.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","394.14","394.14","394.14","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","695.59","432.23","5062.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","4755.81","153.36","5796.1","51","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Imaging with Contrast","5572","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","513.94","513.94","1027.88","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","6376.64","6376.64","6376.64","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1159.67","1159.67","1159.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1322.39","1138.94","1358.35","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","4721.11","4721.11","4721.11","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Imaging with Contrast","5573","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1650.88","1650.88","1925.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","5076.89","5076.89","5076.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","3220.5","3220.5","3220.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","262.43","262.43","262.43","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","3348.5","2281.42","11019.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2533.46","2533.46","2533.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","2572.1","2572.1","8782.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","3302.08","3302.08","5177.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","3617.67","3617.67","3617.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","578.26","578.26","578.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","3220.5","3220.5","3810.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","2802.41","2802.41","4460.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2988.75","2988.75","2988.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","655.07","655.07","655.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","3973.06","3973.06","4087.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","774.6","774.6","774.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","3525.88","3525.88","3525.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3380.56","3380.56","4585","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4925.97","4925.97","4925.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","8734.5","8734.5","8734.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","712.11","712.11","1214.79","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","9625.92","8444.88","19793.85","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1924.04","1878.65","1924.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","7328.98","7328.98","9828.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1878.65","1878.65","2969.34","13","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","7182.46","4840.85","9221.27","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","11323.07","11323.07","26171.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","13008","8566.5","22291.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","745.77","745.77","745.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","5250.08","3716.4","5452.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1883.65","1879.56","3238.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","8556.75","8556.75","13262.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","8556.75","8556.75","8556.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","6731.31","6731.31","14026.66","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","4119.12","3035.14","6007.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","8442.66","8442.66","13085.42","33","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2149.71","2098.98","5140.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","7279.65","6833.99","18549.12","13","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2099.48","2099.48","5545.54","66","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","8932.71","8773.52","16669.83","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","6959.49","6959.49","6959.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","8712","8556.75","16291.64","14","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","8867.82","8867.82","8867.82","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","3037.1","3037.1","3037.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5567.67","5567.67","5567.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","9068.59","1149","16445.76","20","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3240","2098.99","5125.82","28","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","1251.34","1251.34","1251.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","191.56","191.56","191.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","376.53","376.53","376.53","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","5573.25","5573.25","5573.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","4380.8","4380.8","53018.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","539.52","539.52","728.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","49316.72","49316.72","49316.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","712.74","712.74","712.74","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","69176.25","69176.25","69176.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","6769.19","6769.19","6769.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","2587.51","2587.51","3261.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","32271.4","32271.4","47436.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","5271.76","5271.76","5686.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","20345.96","20345.96","20345.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","26014.34","26014.34","26014.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","44926.33","44926.33","44926.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","5929.52","5929.52","5929.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3642.17","3642.17","3642.17","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","26639.26","4138.08","85400.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","6174.62","3605.26","7807.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","47803.08","47803.08","47803.08","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","35561.25","35209.5","61038.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","947.97","947.97","11999.3","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Radiation Therapy","5622","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","48425.25","48425.25","48425.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","76141.86","56192.19","105245.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","6462","1692.61","141947","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","43630.4","21630.2","104173.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","9112.74","7644.42","15620.82","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","86553.17","44629.12","95383.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7879.18","1545.2","19659.79","16","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","14387.54","14387.54","14387.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","78138.75","9283.5","111472.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","8240.51","8240.51","8240.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","56848.76","56848.76","109907.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Radiation Therapy","5623","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","4353.37","4353.37","13020.36","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","17050.98","17050.98","17050.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","6783.51","6783.51","6783.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","33650.02","33650.02","42209.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","12292.4","12292.4","12292.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8124.16","5246.24","13342.57","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","34967.24","34967.24","34967.24","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","15749.41","15749.41","15749.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","83757","83757","83757","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","45650.92","45650.92","45650.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 6 Radiation Therapy","5626","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7771.62","7771.62","7771.62","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","12026.48","3270.8","17159.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","10166.62","10166.62","10166.62","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3356.69","3356.69","3356.69","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapeutic Nuclear Medicine","5661","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","585.75","551.25","917.25","17","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","603.75","603.75","603.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","329.22","329.22","329.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","61.16","61.16","61.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","577.94","484.7","792.54","69","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","482.2","482.2","482.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","619.05","600.59","1120.43","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","585.75","528.75","732","22","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","611.8","570.76","898.32","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Pathology","5671","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","1778.22","1778.22","2157.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","252.55","252.55","252.55","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2039.63","2039.63","2039.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","1258.5","1258.5","1258.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","603.32","603.32","603.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","3862.68","3862.68","3862.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","365.25","365.25","365.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3613.8","3613.8","4208.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Pathology","5672","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1095.75","1095.75","1095.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","71.81","71.81","71.81","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","891.7","480.26","2424.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","1614","1614","1698","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","1086.8","1086.8","1086.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","768.63","768.63","768.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Pathology","5673","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","540.65","540.65","540.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","19220.1","19220.1","19220.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","15636.94","15636.94","15636.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1205.39","1205.39","1205.39","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","30036.48","30036.48","30036.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","4893.26","872.89","27098.06","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","102.42","102.42","102.42","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","586.41","586.41","586.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3862.14","102.92","121532.51","16","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","21072.43","21072.43","21072.43","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","538.5","538.5","12549.83","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","944.68","944.68","944.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","235.25","235.25","235.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","1064.92","397.48","11661.35","13","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Drug Administration","5692","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","3557.51","3557.51","3557.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1906.13","1027.5","3515.25","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","1962.75","1027.5","2930.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","2513.07","1982.5","2973.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","371.7","226.2","469.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","2027.6","1013.8","7666.24","59","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","618.52","309.26","2475.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","1919.11","1919.11","1919.11","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1720.81","370.09","6277.46","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","1562.16","577.71","4402.76","17","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","1962.75","1443","3781.58","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","105.48","105.48","105.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","184.8","99.56","255.35","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","1103.84","255.34","3123.6","25","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Drug Administration","5693","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1725.05","606.4","3144.23","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","12531.44","8054.65","24082.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","26247.09","6362.25","52494.18","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","40512.07","40512.07","40512.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","22703.12","1267.14","45406.24","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","31316.44","3714.8","60258.42","48","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","7969.21","1538.76","20625","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","14402.76","9938.52","65492.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","8424.26","2410.27","15986.13","45","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","30186.18","4796.22","57077.02","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","19792.68","19792.68","27331.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","24010.55","24010.55","24010.55","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","34155.66","34155.66","39657.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","22691.67","4900.5","55676.21","21","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","59776.65","59776.65","59776.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","637.5","637.5","664.87","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","3272","1174.42","65193.08","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Drug Administration","5694","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","13260.86","2697.85","24296.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","562.5","562.5","1233","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","37.15","37.15","81.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","555","555","1224.7","28","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","230.6","230.6","230.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","772.31","772.31","881.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","449.25","449.25","894.91","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","227.16","227.16","227.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","576.75","534","1518.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","100","100","100","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","732.89","562.5","1241.25","14","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","321.06","321.06","321.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","577.74","577.74","1000.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","225.16","225.16","225.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","7077.01","7077.01","7077.01","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","1916.43","665.52","2586.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","457.27","457.27","457.27","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","1831.63","1533.28","7030.74","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","450.52","448.12","458.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","1945.66","1241.13","5579.69","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","448.12","448.12","601.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","1903.42","1593.37","3781.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","1856.39","1554","2918.39","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","544.32","544.32","544.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","168.28","168.28","168.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","783","783","783","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","2542.96","1574.72","7220.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","448.13","448.13","896.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","2969.25","2969.25","2969.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","4024.5","4024.5","4024.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","2914.86","2914.86","2922.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","39.56","39.56","39.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","3029.09","3029.09","3029.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","2359.46","2359.46","2359.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","765.56","765.56","765.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","4722.33","4722.33","4722.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1980.01","1980.01","1980.01","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","1978.03","1978.03","1978.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","301.5","301.5","301.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","237.18","237.18","237.18","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","19.64","19.64","19.64","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","297.48","297.48","297.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","57.85","57.85","57.85","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","309.14","307","309.14","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","528","528","528","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","305.52","305.52","305.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 2 Minor Procedures","5732","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","226.5","187.5","800.25","30","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","226.5","226.5","514.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","147.5","76.11","487.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","44.69","22.96","147.05","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","223.48","95.46","706.7","72","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","87.54","85.48","87.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","397.14","180.9","624.01","16","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","85.48","85.48","85.48","43","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","329.9","215.02","862.82","32","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","215.02","215.02","215.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","321.75","187.5","1396.5","33","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","22.58","22.58","22.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","66.96","66.96","66.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","278.92","98.04","725.8","30","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Minor Procedures","5733","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","85.48","85.48","86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","851.25","248.25","2184","27","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","828.75","794.25","1714.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","448.4","177","3856.18","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","151.32","18.28","677.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","783.66","236.8","2154.88","73","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","186.09","185.49","189.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","790.68","455.24","1520.23","14","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","185.49","185.49","185.49","31","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","849.74","235.67","1837.91","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","828.75","447","2184","32","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","242.58","242.58","242.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","17.81","17.81","17.81","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","14.15","14.15","94.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","736.44","228","1662.12","41","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 4 Minor Procedures","5734","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","185.5","185.5","186.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","6427.31","6427.31","6427.31","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","11600.98","11569.9","20722.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","941.68","941.68","2081.79","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","941.68","941.68","943.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","7684.27","7684.27","7684.27","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","3432","3432","3432","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","5245.5","5245.5","5245.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","454.5","227.25","454.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","429.28","429.28","429.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","448.44","224.22","1121.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","178.77","178.77","178.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","215.74","215.74","516.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","242.4","242.4","932.8","13","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","448.44","448.44","460.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","690.84","230.28","1042.74","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Level 3 Health and Behavior Services","5823","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","1850","1850","1850","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","9891.82","9891.82","9891.82","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Piflu f-18, dia 1 millicurie","9430","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","10051.42","10051.42","10051.42","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","2218.82","2218.82","2218.82","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Plate pheres leukoredu irrad","9530","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","208.5","137.25","266.25","96","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","208.5","169.5","345.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","164.02","114.46","200.01","36","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","205.72","135.42","212.38","298","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","166.52","135.37","203.06","50","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","213.78","149.19","220.7","97","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","208.5","137.25","254.25","151","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","139.08","139.08","218.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","211.28","139.08","269.8","133","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-OPPS Clinic Services","N700","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","437.25","82.5","1386","595","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","413.25","39","1348.5","106","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","382.91","60.77","961.11","110","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","65.62","18.06","169.86","127","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","483.22","89.54","1343.84","1421","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","36.6","7.61","103.44","105","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","418.7","121.6","1092.27","317","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","35.88","13.83","108.34","553","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","555.98","116.88","1421.1","454","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","769.2","769.2","769.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","428.25","124.5","1386","763","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","369.37","12.11","470.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","447.64","30","943.92","30","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","45.19","15.52","115.93","41","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","34.53","21.32","80.62","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","135.22","135.22","135.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","513.76","110.96","1404.48","788","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Clinical Diagnostic Lab Services","N800","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","36.11","16.47","113.46","205","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","717","515.25","1332","40","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","750","515.25","1219.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","822.46","405.33","1650.82","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","184.34","92.17","276.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","747.4","508.38","1582.12","117","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","160.06","75.98","324.66","20","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","823.02","411.51","1252.5","26","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","168.61","84.71","308.47","89","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","712","489.14","1600.28","55","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","535.5","219","1272.75","123","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","537.32","537.32","721.24","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","100","100","100","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","713.64","311.6","1581.56","69","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Therapy Services","N801","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","169.78","76.3","306.94","27","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","574.5","574.5","574.5","214","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","574.5","574.5","574.5","23","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","451.94","451.94","451.94","52","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","182.54","155.01","210.37","23","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","566.84","566.84","566.84","682","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","156.68","156.68","175.34","23","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","458.83","458.83","458.83","196","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","227.06","171.21","227.06","540","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","589.05","589.05","589.05","204","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","199.85","199.85","589.05","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","574.5","574.5","574.5","283","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","582.16","582.16","582.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","155.01","155.01","155.01","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","156.68","156.68","156.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","582.16","582.16","582.16","406","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Mammography Services","N804","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","156.69","156.69","171.21","95","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","65.25","65.25","65.25","101","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","51.33","51.33","51.33","52","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","43.62","43.62","43.62","29","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","64.38","64.38","64.38","299","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","30.39","30.39","31","54","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","52.11","52.11","52.11","81","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","31.01","30.39","31.01","99","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","66.9","66.9","87","102","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","29.77","29.77","29.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]","53.07","53.07","53.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","65.25","65.25","65.25","76","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","66.12","66.12","66.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","27.53","27.53","27.53","24","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","32.12","32.12","32.12","17","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","30.51","30.51","30.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","32.12","32.12","32.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","66.12","66.12","66.12","102","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Medicine","N809","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","30.39","30.39","30.39","70","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","402","402","402","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Observation, Other","N811","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","850.5","626.25","850.5","38","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","850.5","850.5","850.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","669.06","492.65","669.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","839.16","617.9","839.16","129","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","679.26","500.17","679.26","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]","150.07","147.67","408.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","872.04","642.12","872.04","37","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","850.5","626.25","850.5","51","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]","861.84","861.84","861.84","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","861.84","634.6","861.84","64","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Non-covered Services","N900","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","731.25","731.25","731.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","562.2","562.2","6877.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","130.02","130.02","130.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","198.56","120.09","934.86","17","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]","119.14","93.32","160.83","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","45.7","45.7","45.7","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","370.17","370.17","370.17","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","1223.6","497.9","16087.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Packaged Services","N902","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]","5271.78","726","5296.87","34","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19554] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [OP ECT Mental Health (%BC): 75] [Trauma (%BC): 76] [All Other OP (%BC): 75]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual",,,"[Lesser Than Charges paid at %: 100.00] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 14840] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 60] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 60] [All Other OP (%BC): 59]","4375.99","4375.99","4424.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Bariatric Surgery ($): 45344] [Observation-Per Hour: 111] [Gamma Knife ($): 54378] [Trauma (%BC): 60]","371.95","338.8","507.45","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19582] [CT Scan OP ($): Fee Schedule] [OP ECT Mental Health (%BC): 75] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 75] [All Other OP (%BC): 74]","5728.89","716.32","5770.16","66","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 16849] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 60.5] [Trauma (%BC): 75.7] [All Other OP (%BC): 59.3]","3988.24","579.83","4021.65","28","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20655] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 76.1] [OP ECT Mental Health (%BC): 76.5] [OP High Cost Drugs Fee Schedule: Fee Schedule] [All Other OP (%BC): 76.1]","5100.12","744.39","5123.71","20","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 18112] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP ECT Mental Health (%BC): 76.4] [Trauma (%BC): 76.4] [All Other OP (%BC): 70.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[OP Surgery  (%BC): 62] [Bariatric Surgery ($): 15898] [OP ECT Mental Health (%BC): 66] [All Other OP (%BC): 62]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 19749] [Emergency Department (%BC): 75] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Laboratory (%BC): 75] [Trauma (%BC): 85] [All Other OP (%BC): 75]","5200.13","726","5252.42","38","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO",,,"[Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 20926] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [Trauma (%BC): 77] [All Other OP (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Health Net","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO",,,"[Lesser Than Charges paid at %: 100.00] [Outpatient Services: Fixed rates applicable to non-emergency services only.] [OP Surgery Group ($): Fee Schedule] [Bariatric Surgery ($): 24055] [Emergency Department (%BC): 76] [CT Scan OP ($): Fee Schedule] [MRI OP ($): Fee Schedule] [Positron Emission Tomography ($): Fee Schedule] [OP High Cost Drugs Fee Schedule: Fee Schedule] [Trauma (%BC): 82] [All Other OP (%BC): 76]","4988.55","484","5027.27","55","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Not Recognized by OPPS","N905","APC",,,,,,,"facility","outpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[APC ($): 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"HCHG ROOM TELEMETRY DEDICATED CORONARY CARE UNIT","10000000","CDM","214","RC",,,,,"facility","inpatient",,,,"6508","6508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TELEMETRY DEDICATED CORONARY CARE UNIT","10000000","CDM","214","RC",,,,,"facility","outpatient",,,,"6508","6508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM MED/SURG/GYN","10000003","CDM","121","RC",,,,,"facility","inpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM MED/SURG/GYN","10000003","CDM","121","RC",,,,,"facility","outpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM OB/MATERNAL","10000004","CDM","122","RC",,,,,"facility","inpatient",,,,"6632","6632",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM OB/MATERNAL","10000004","CDM","122","RC",,,,,"facility","outpatient",,,,"6632","6632",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM PEDIATRIC","10000005","CDM","123","RC",,,,,"facility","inpatient",,,,"8926","8926",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM PEDIATRIC","10000005","CDM","123","RC",,,,,"facility","outpatient",,,,"8926","8926",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM BEHAVIORAL HEALTH","10000006","CDM","124","RC",,,,,"facility","inpatient",,,,"3588","3588",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM BEHAVIORAL HEALTH","10000006","CDM","124","RC",,,,,"facility","outpatient",,,,"3588","3588",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN BOARDER BABY","10000008","CDM","171","RC",,,,,"facility","inpatient",,,,"3141","3141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN BOARDER BABY","10000008","CDM","171","RC",,,,,"facility","outpatient",,,,"3141","3141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN LEVEL I","10000009","CDM","171","RC",,,,,"facility","inpatient",,,,"2416","2416",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN LEVEL I","10000009","CDM","171","RC",,,,,"facility","outpatient",,,,"2416","2416",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN LEVEL II","10000010","CDM","172","RC",,,,,"facility","inpatient",,,,"12986","12986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN LEVEL II","10000010","CDM","172","RC",,,,,"facility","outpatient",,,,"12986","12986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN LEVEL III","10000011","CDM","173","RC",,,,,"facility","inpatient",,,,"17855","17855",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN LEVEL III","10000011","CDM","173","RC",,,,,"facility","outpatient",,,,"17855","17855",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN LEVEL IV","10000012","CDM","174","RC",,,,,"facility","inpatient",,,,"32464","32464",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN LEVEL IV","10000012","CDM","174","RC",,,,,"facility","outpatient",,,,"32464","32464",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN ECMO","10000013","CDM","174","RC",,,,,"facility","inpatient",,,,"38957","38957",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEWBORN ECMO","10000013","CDM","174","RC",,,,,"facility","outpatient",,,,"38957","38957",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE VENT","10000014","CDM",,,,,,,"facility","inpatient",,,,"4750","4750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE VENT","10000014","CDM",,,,,,,"facility","outpatient",,,,"4750","4750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE NON VENT","10000015","CDM",,,,,,,"facility","inpatient",,,,"4479","4479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE NON VENT","10000015","CDM",,,,,,,"facility","outpatient",,,,"4479","4479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM ICU","10000016","CDM","200","RC",,,,,"facility","inpatient",,,,"16541","16541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM ICU","10000016","CDM","200","RC",,,,,"facility","outpatient",,,,"16541","16541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM ICU PEDIATRICS","10000017","CDM","203","RC",,,,,"facility","inpatient",,,,"16541","16541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM ICU PEDIATRICS","10000017","CDM","203","RC",,,,,"facility","outpatient",,,,"16541","16541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM ICU INTERM","10000018","CDM","206","RC",,,,,"facility","inpatient",,,,"7509","7509",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM ICU INTERM","10000018","CDM","206","RC",,,,,"facility","outpatient",,,,"7509","7509",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SPECIAL CARE","10000019","CDM","206","RC",,,,,"facility","inpatient",,,,"6508","6508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SPECIAL CARE","10000019","CDM","206","RC",,,,,"facility","outpatient",,,,"6508","6508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM CCU","10000020","CDM","210","RC",,,,,"facility","inpatient",,,,"15056","15056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM CCU","10000020","CDM","210","RC",,,,,"facility","outpatient",,,,"15056","15056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSTNCT","10000021","CDM","121","RC",,,,,"facility","inpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSTNCT","10000021","CDM","121","RC",,,,,"facility","outpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSTNCT BED HOLD","10000026","CDM","121","RC",,,,,"facility","inpatient",,,,"8510","8510",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSTNCT BED HOLD","10000026","CDM","121","RC",,,,,"facility","outpatient",,,,"8510","8510",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE VENT BED HOLD","10000027","CDM",,,,,,,"facility","inpatient",,,,"4750","4750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE VENT BED HOLD","10000027","CDM",,,,,,,"facility","outpatient",,,,"4750","4750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE NON VENT BED HOLD","10000028","CDM",,,,,,,"facility","inpatient",,,,"4479","4479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE NON VENT BED HOLD","10000028","CDM",,,,,,,"facility","outpatient",,,,"4479","4479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM MED/SURG/GYN PVT","10000029","CDM","111","RC",,,,,"facility","inpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM MED/SURG/GYN PVT","10000029","CDM","111","RC",,,,,"facility","outpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM OB/MATERNAL PVT","10000036","CDM","112","RC",,,,,"facility","inpatient",,,,"6632","6632",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM OB/MATERNAL PVT","10000036","CDM","112","RC",,,,,"facility","outpatient",,,,"6632","6632",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM PEDIATRIC PVT","10000037","CDM","113","RC",,,,,"facility","inpatient",,,,"8926","8926",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM PEDIATRIC PVT","10000037","CDM","113","RC",,,,,"facility","outpatient",,,,"8926","8926",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM BEHAVIORL HEALTH PVT","10000038","CDM","114","RC",,,,,"facility","inpatient",,,,"6099","6099",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM BEHAVIORL HEALTH PVT","10000038","CDM","114","RC",,,,,"facility","outpatient",,,,"6099","6099",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSNCT PVT","10000041","CDM","111","RC",,,,,"facility","inpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSNCT PVT","10000041","CDM","111","RC",,,,,"facility","outpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LABOR & DELIVERY ROOM & BOARD PLACEHOLDER","10000047","CDM","122","RC",,,,,"facility","inpatient",,,,"1","1",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LABOR & DELIVERY ROOM & BOARD PLACEHOLDER","10000047","CDM","122","RC",,,,,"facility","outpatient",,,,"1","1",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 1 NON VENT","10000048","CDM","191","RC",,,,,"facility","inpatient",,,,"4798","4798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 1 NON VENT","10000048","CDM","191","RC",,,,,"facility","outpatient",,,,"4798","4798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 2 NON VENT","10000049","CDM","192","RC",,,,,"facility","inpatient",,,,"5337","5337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 2 NON VENT","10000049","CDM","192","RC",,,,,"facility","outpatient",,,,"5337","5337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 3 NON VENT","10000050","CDM","193","RC",,,,,"facility","inpatient",,,,"6078","6078",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 3 NON VENT","10000050","CDM","193","RC",,,,,"facility","outpatient",,,,"6078","6078",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 4 NON VENT","10000051","CDM","194","RC",,,,,"facility","inpatient",,,,"5250","5250",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 4 NON VENT","10000051","CDM","194","RC",,,,,"facility","outpatient",,,,"5250","5250",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM MED/SURG/GYN PVT MJ","10000063","CDM","111","RC",,,,,"facility","inpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM MED/SURG/GYN PVT MJ","10000063","CDM","111","RC",,,,,"facility","outpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY COMING HOME HOSPICE","10000067","CDM",,,,,,,"facility","inpatient",,,,"300","300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY COMING HOME HOSPICE","10000067","CDM",,,,,,,"facility","outpatient",,,,"300","300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMFORT CARE R&B PLACEHOLDER","10000074","CDM","170","RC",,,,,"facility","inpatient",,,,"1","1",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMFORT CARE R&B PLACEHOLDER","10000074","CDM","170","RC",,,,,"facility","outpatient",,,,"1","1",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM LOA NO CHARGE","10000075","CDM","180","RC",,,,,"facility","inpatient",,,,"1","1",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM LOA NO CHARGE","10000075","CDM","180","RC",,,,,"facility","outpatient",,,,"1","1",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM HOSPICE PRIVATE","10000076","CDM","115","RC",,,,,"facility","inpatient",,,,"4620","4620",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM HOSPICE PRIVATE","10000076","CDM","115","RC",,,,,"facility","outpatient",,,,"4620","4620",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM HOSPICE SEMI PRIVATE","10000077","CDM","125","RC",,,,,"facility","inpatient",,,,"4449","4449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM HOSPICE SEMI PRIVATE","10000077","CDM","125","RC",,,,,"facility","outpatient",,,,"4449","4449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM REHAB ACUTE SEMI PVT","10000078","CDM","128","RC",,,,,"facility","inpatient",,,,"6270","6270",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM REHAB ACUTE SEMI PVT","10000078","CDM","128","RC",,,,,"facility","outpatient",,,,"6270","6270",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 1 VENT","10000089","CDM","191","RC",,,,,"facility","inpatient",,,,"4798","4798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 1 VENT","10000089","CDM","191","RC",,,,,"facility","outpatient",,,,"4798","4798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 2 VENT","10000090","CDM","192","RC",,,,,"facility","inpatient",,,,"5363","5363",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 2 VENT","10000090","CDM","192","RC",,,,,"facility","outpatient",,,,"5363","5363",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 3 VENT","10000091","CDM","193","RC",,,,,"facility","inpatient",,,,"5728","5728",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 3 VENT","10000091","CDM","193","RC",,,,,"facility","outpatient",,,,"5728","5728",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 4 VENT","10000092","CDM","194","RC",,,,,"facility","inpatient",,,,"6718","6718",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE LVL 4 VENT","10000092","CDM","194","RC",,,,,"facility","outpatient",,,,"6718","6718",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM NON-COVERED CUSTODIAL CARE","10000093","CDM","129","RC",,,,,"facility","inpatient",,,,"2412","2412",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM NON-COVERED CUSTODIAL CARE","10000093","CDM","129","RC",,,,,"facility","outpatient",,,,"2412","2412",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED ROOM & BOARD","10000094","CDM","121","RC",,,,,"facility","inpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED ROOM & BOARD","10000094","CDM","121","RC",,,,,"facility","outpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OR ROOM & BOARD","10000096","CDM","121","RC",,,,,"facility","inpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OR ROOM & BOARD","10000096","CDM","121","RC",,,,,"facility","outpatient",,,,"5006","5006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TELEMETRY","10000097","CDM","206","RC",,,,,"facility","inpatient",,,,"6508","6508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TELEMETRY","10000097","CDM","206","RC",,,,,"facility","outpatient",,,,"6508","6508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TRANSPLANT MED/SURG/GYN","10000099","CDM","121","RC",,,,,"facility","inpatient",,,,"7509","7509",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TRANSPLANT MED/SURG/GYN","10000099","CDM","121","RC",,,,,"facility","outpatient",,,,"7509","7509",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TRANSPLANT ICU","10000100","CDM","200","RC",,,,,"facility","inpatient",,,,"24812","24812",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TRANSPLANT ICU","10000100","CDM","200","RC",,,,,"facility","outpatient",,,,"24812","24812",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TRANSPLANT ICU INTERM","10000101","CDM","206","RC",,,,,"facility","inpatient",,,,"11263","11263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TRANSPLANT ICU INTERM","10000101","CDM","206","RC",,,,,"facility","outpatient",,,,"11263","11263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TRANSPLANT TELEMETRY","10000102","CDM","206","RC",,,,,"facility","inpatient",,,,"9761","9761",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM TRANSPLANT TELEMETRY","10000102","CDM","206","RC",,,,,"facility","outpatient",,,,"9761","9761",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM ICU ECMO","10000105","CDM","200","RC",,,,,"facility","inpatient",,,,"19849","19849",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM ICU ECMO","10000105","CDM","200","RC",,,,,"facility","outpatient",,,,"19849","19849",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSTNCT NONDD BED HOLD","10000107","CDM","121","RC",,,,,"facility","inpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSTNCT NONDD BED HOLD","10000107","CDM","121","RC",,,,,"facility","outpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSTNCT DD BED HOLD","10000108","CDM","121","RC",,,,,"facility","inpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SNF M/S DSTNCT DD BED HOLD","10000108","CDM","121","RC",,,,,"facility","outpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE NON VENT BED HOLD","10000109","CDM","121","RC",,,,,"facility","inpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE NON VENT BED HOLD","10000109","CDM","121","RC",,,,,"facility","outpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE VENT BED HOLD","10000110","CDM","121","RC",,,,,"facility","inpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROOM SUBACUTE VENT BED HOLD","10000110","CDM","121","RC",,,,,"facility","outpatient",,,,"4255","4255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CPR","10100004","CDM","760","RC","92950","HCPCS",,,"facility","inpatient",,,,"2784","2784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CPR","10100004","CDM","760","RC","92950","HCPCS",,,"facility","outpatient",,,,"2784","2784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS PER HOUR","10100005","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"268","268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS PER HOUR","10100005","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"268","268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DIRECT ADMIT","10100007","CDM","762","RC","G0379","HCPCS",,,"facility","inpatient",,,,"1099","1099",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DIRECT ADMIT","10100007","CDM","762","RC","G0379","HCPCS",,,"facility","outpatient",,,,"1099","1099",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INTRODUCTION NEEDLE OR INTRACATHETER INTO VEIN","10100008","CDM","760","RC","36000","HCPCS",,,"facility","inpatient",,,,"603","603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INTRODUCTION NEEDLE OR INTRACATHETER INTO VEIN","10100008","CDM","760","RC","36000","HCPCS",,,"facility","outpatient",,,,"603","603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS BLOOD DRAW IMPLANTED PORT","10100009","CDM","760","RC","36591","HCPCS",,,"facility","inpatient",,,,"447","447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS BLOOD DRAW IMPLANTED PORT","10100009","CDM","760","RC","36591","HCPCS",,,"facility","outpatient",,,,"447","447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DECLOT VASCULAR DEVICE WITH THROMBOLYTIC","10100010","CDM","760","RC","36593","HCPCS",,,"facility","inpatient",,,,"1307","1307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DECLOT VASCULAR DEVICE WITH THROMBOLYTIC","10100010","CDM","760","RC","36593","HCPCS",,,"facility","outpatient",,,,"1307","1307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CENTRAL VENOUS CATH INSERTION NON-TUNNELED 5YR OR OLDER","10100011","CDM","760","RC","36556","HCPCS",,,"facility","inpatient",,,,"4383","4383",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CENTRAL VENOUS CATH INSERTION NON-TUNNELED 5YR OR OLDER","10100011","CDM","760","RC","36556","HCPCS",,,"facility","outpatient",,,,"4383","4383",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS IRRIGATION BLADDER SIMPLE","10100012","CDM","760","RC","51700","HCPCS",,,"facility","inpatient",,,,"1421","1421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS IRRIGATION BLADDER SIMPLE","10100012","CDM","760","RC","51700","HCPCS",,,"facility","outpatient",,,,"1421","1421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INSERT STRAIGHT CATHETER","10100013","CDM","760","RC","51701","HCPCS",,,"facility","inpatient",,,,"681","681",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INSERT STRAIGHT CATHETER","10100013","CDM","760","RC","51701","HCPCS",,,"facility","outpatient",,,,"681","681",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INSERTION FOLEY CATHETER","10100014","CDM","760","RC","51702","HCPCS",,,"facility","inpatient",,,,"768","768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INSERTION FOLEY CATHETER","10100014","CDM","760","RC","51702","HCPCS",,,"facility","outpatient",,,,"768","768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS THORACENTESIS W/IMAG","10100047","CDM","760","RC","32555","HCPCS",,,"facility","inpatient",,,,"3790","3790",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS THORACENTESIS W/IMAG","10100047","CDM","760","RC","32555","HCPCS",,,"facility","outpatient",,,,"3790","3790",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS THORACENTESIS WO IMAG","10100048","CDM","760","RC","32554","HCPCS",,,"facility","inpatient",,,,"3229","3229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS THORACENTESIS WO IMAG","10100048","CDM","760","RC","32554","HCPCS",,,"facility","outpatient",,,,"3229","3229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS PERCUTANEOUS LIVER BIOPSY","10100056","CDM","760","RC","47000","HCPCS",,,"facility","inpatient",,,,"4749","4749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS PERCUTANEOUS LIVER BIOPSY","10100056","CDM","760","RC","47000","HCPCS",,,"facility","outpatient",,,,"4749","4749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS IMAGE CATH FLUID PERI/RETRO","10100058","CDM","760","RC","49406","HCPCS",,,"facility","inpatient",,,,"5613","5613",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS IMAGE CATH FLUID PERI/RETRO","10100058","CDM","760","RC","49406","HCPCS",,,"facility","outpatient",,,,"5613","5613",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INS PACK FOR NON-OB VAG HEMORRHAGE","10100064","CDM","760","RC","57180","HCPCS",,,"facility","inpatient",,,,"671","671",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INS PACK FOR NON-OB VAG HEMORRHAGE","10100064","CDM","760","RC","57180","HCPCS",,,"facility","outpatient",,,,"671","671",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INSERT PICC >=5 YR WO PORT WO IMAGE GUIDANC","10100073","CDM","760","RC","36569","HCPCS",,,"facility","inpatient",,,,"4268","4268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INSERT PICC >=5 YR WO PORT WO IMAGE GUIDANC","10100073","CDM","760","RC","36569","HCPCS",,,"facility","outpatient",,,,"4268","4268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INSERT PICC >=5 YR WO PORT W IMAGE GUIDANCE","10100075","CDM","760","RC","36573","HCPCS",,,"facility","inpatient",,,,"4868","4868",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INSERT PICC >=5 YR WO PORT W IMAGE GUIDANCE","10100075","CDM","760","RC","36573","HCPCS",,,"facility","outpatient",,,,"4868","4868",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR RADIOLOGY","10100081","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR RADIOLOGY","10100081","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR RESPIRATORY","10100082","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR RESPIRATORY","10100082","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR CARDIOLOGY","10100083","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR CARDIOLOGY","10100083","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR GI","10100084","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR GI","10100084","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR INTERVENTIONAL RAD","10100085","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR INTERVENTIONAL RAD","10100085","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR CARDIAC CATH","10100086","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR CARDIAC CATH","10100086","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR PT OT SPEECH","10100087","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR PT OT SPEECH","10100087","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR DIALYSIS","10100088","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR DIALYSIS","10100088","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR EEG","10100089","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR EEG","10100089","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR CHEMO ADMIN","10100090","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR CHEMO ADMIN","10100090","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR BLOOD TRANSFUSION","10100091","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR BLOOD TRANSFUSION","10100091","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR NUCLEAR MED","10100092","CDM","762","RC","G0378","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARVE OUT PER HOUR NUCLEAR MED","10100092","CDM","762","RC","G0378","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DRN ABSCESS SMPL/SNGL","10100205","CDM","760","RC","10060","HCPCS",,,"facility","inpatient",,,,"1268","1268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DRN ABSCESS SMPL/SNGL","10100205","CDM","760","RC","10060","HCPCS",,,"facility","outpatient",,,,"1241","1241",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS COL BLD PICC/CNTRL LN","10100207","CDM","760","RC","36592","HCPCS",,,"facility","inpatient",,,,"526","526",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS COL BLD PICC/CNTRL LN","10100207","CDM","760","RC","36592","HCPCS",,,"facility","outpatient",,,,"526","526",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARDIOVERSION ELECTRIC EXTERNAL","10100209","CDM","760","RC","92960","HCPCS",,,"facility","inpatient",,,,"4162","4162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS CARDIOVERSION ELECTRIC EXTERNAL","10100209","CDM","760","RC","92960","HCPCS",,,"facility","outpatient",,,,"4162","4162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INFUSN CHEMO 0-60 MN","10100212","CDM","760","RC","96413","HCPCS",,,"facility","inpatient",,,,"1768","1768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INFUSN CHEMO 0-60 MN","10100212","CDM","760","RC","96413","HCPCS",,,"facility","outpatient",,,,"1768","1768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INFUSN CHEM EA ADD HR","10100213","CDM","760","RC","96415","HCPCS",,,"facility","inpatient",,,,"684","684",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS INFUSN CHEM EA ADD HR","10100213","CDM","760","RC","96415","HCPCS",,,"facility","outpatient",,,,"684","684",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DX NASAL ENDOSCOPY","10100227","CDM","760","RC","31231","HCPCS",,,"facility","inpatient",,,,"929","929",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DX NASAL ENDOSCOPY","10100227","CDM","760","RC","31231","HCPCS",,,"facility","outpatient",,,,"929","929",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DRAIN/INJ MAJOR JOINT/BURSA W/O US","10100233","CDM","760","RC","20610","HCPCS",,,"facility","inpatient",,,,"1979","1979",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DRAIN/INJ MAJOR JOINT/BURSA W/O US","10100233","CDM","760","RC","20610","HCPCS",,,"facility","outpatient",,,,"1865","1865",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS LUMBAR PUNCTURE DX","10100239","CDM","760","RC","62270","HCPCS",,,"facility","inpatient",,,,"3056","3056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS LUMBAR PUNCTURE DX","10100239","CDM","760","RC","62270","HCPCS",,,"facility","outpatient",,,,"3056","3056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS PARACENTSIS ABD NO IM","10100240","CDM","760","RC","49082","HCPCS",,,"facility","inpatient",,,,"3084","3084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS PARACENTSIS ABD NO IM","10100240","CDM","760","RC","49082","HCPCS",,,"facility","outpatient",,,,"3084","3084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DIAGNOSTIC BONE MARROW BIOPSY","10100242","CDM","760","RC","38221","HCPCS",,,"facility","inpatient",,,,"4081","4081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS DIAGNOSTIC BONE MARROW BIOPSY","10100242","CDM","760","RC","38221","HCPCS",,,"facility","outpatient",,,,"4081","4081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT WCOMP AQUATIC PRIOR AUTH INDIVIDUAL","17000048","CDM",,,,,,,"facility","inpatient",,,,"289","289",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT WCOMP AQUATIC PRIOR AUTH INDIVIDUAL","17000048","CDM",,,,,,,"facility","outpatient",,,,"289","289",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL SINGLE MODALITY ADDITIONAL 15 MIN","17000058","CDM",,,,,,,"facility","inpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL SINGLE MODALITY ADDITIONAL 15 MIN","17000058","CDM",,,,,,,"facility","outpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL SINGLE PROCURE INITIAL 30 MIN","17000059","CDM",,,,,,,"facility","inpatient",,,,"602","602",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL SINGLE PROCURE INITIAL 30 MIN","17000059","CDM",,,,,,,"facility","outpatient",,,,"602","602",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL SINGLE PROCURE ADDITIONAL 15 MIN","17000060","CDM",,,,,,,"facility","inpatient",,,,"307","307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL SINGLE PROCURE ADDITIONAL 15 MIN","17000060","CDM",,,,,,,"facility","outpatient",,,,"307","307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL TREAT COMBO INIT 30","17000062","CDM",,,,,,,"facility","inpatient",,,,"484","484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL TREAT COMBO INIT 30","17000062","CDM",,,,,,,"facility","outpatient",,,,"484","484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL TX COMB PROC/MODALITIES ADDL 15 MN","17000063","CDM",,,,,,,"facility","inpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL TX COMB PROC/MODALITIES ADDL 15 MN","17000063","CDM",,,,,,,"facility","outpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL AQUATIC THERAPY EXERCISE INITIAL 30 MIN","17000064","CDM",,,,,,,"facility","inpatient",,,,"524","524",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL AQUATIC THERAPY EXERCISE INITIAL 30 MIN","17000064","CDM",,,,,,,"facility","outpatient",,,,"524","524",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL AQUATIC THERAPEUTIC EXERCISE ADDITIONAL 15 MIN","17000065","CDM",,,,,,,"facility","inpatient",,,,"252","252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL AQUATIC THERAPEUTIC EXERCISE ADDITIONAL 15 MIN","17000065","CDM",,,,,,,"facility","outpatient",,,,"252","252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL EVALUATION INITIAL 30 MIN","17000067","CDM",,,,,,,"facility","inpatient",,,,"468","468",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL EVALUATION INITIAL 30 MIN","17000067","CDM",,,,,,,"facility","outpatient",,,,"468","468",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL RE-EVALUATION INITIAL 30 MIN","17000068","CDM",,,,,,,"facility","inpatient",,,,"396","396",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL RE-EVALUATION INITIAL 30 MIN","17000068","CDM",,,,,,,"facility","outpatient",,,,"396","396",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL EVALUATION ADDITIONAL 15 MIN","17000071","CDM",,,,,,,"facility","inpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL EVALUATION ADDITIONAL 15 MIN","17000071","CDM",,,,,,,"facility","outpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL RE-EVALUATION ADDITIONAL 15 MIN","17000072","CDM",,,,,,,"facility","inpatient",,,,"255","255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL RE-EVALUATION ADDITIONAL 15 MIN","17000072","CDM",,,,,,,"facility","outpatient",,,,"255","255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT ELECTRICAL STIMULATION ATTENDED EA 15 MIN","17000115","CDM","420","RC","97032","HCPCS",,,"facility","inpatient",,,"GP","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT ELECTRICAL STIMULATION ATTENDED EA 15 MIN","17000115","CDM","420","RC","97032","HCPCS",,,"facility","outpatient",,,"GP","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT IONTOPHORESIS EA 15 MIN","17000116","CDM","420","RC","97033","HCPCS",,,"facility","inpatient",,,"GP","158","158",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT IONTOPHORESIS EA 15 MIN","17000116","CDM","420","RC","97033","HCPCS",,,"facility","outpatient",,,"GP","158","158",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT CONTRAST BATHS EA 15 MIN","17000117","CDM","420","RC","97034","HCPCS",,,"facility","inpatient",,,"GP","123","123",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT CONTRAST BATHS EA 15 MIN","17000117","CDM","420","RC","97034","HCPCS",,,"facility","outpatient",,,"GP","123","123",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT ULTRASOUND EA 15 MIN","17000118","CDM","420","RC","97035","HCPCS",,,"facility","inpatient",,,"GP","162","162",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT ULTRASOUND EA 15 MIN","17000118","CDM","420","RC","97035","HCPCS",,,"facility","outpatient",,,"GP","162","162",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT THERAPEUTIC EXERCISE EA 15 MIN","17000119","CDM","420","RC","97110","HCPCS",,,"facility","inpatient",,,"GP","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT THERAPEUTIC EXERCISE EA 15 MIN","17000119","CDM","420","RC","97110","HCPCS",,,"facility","outpatient",,,"GP","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT NEUROMUSCULAR REEDUCATION EA 15 MIN","17000120","CDM","420","RC","97112","HCPCS",,,"facility","inpatient",,,"GP","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT NEUROMUSCULAR REEDUCATION EA 15 MIN","17000120","CDM","420","RC","97112","HCPCS",,,"facility","outpatient",,,"GP","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT AQUATIC THERAPY EA 15 MIN","17000121","CDM","420","RC","97113","HCPCS",,,"facility","inpatient",,,"GP","243","243",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT AQUATIC THERAPY EA 15 MIN","17000121","CDM","420","RC","97113","HCPCS",,,"facility","outpatient",,,"GP","243","243",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT GAIT TRAINING EA 15 MIN","17000122","CDM","420","RC","97116","HCPCS",,,"facility","inpatient",,,"GP","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT GAIT TRAINING EA 15 MIN","17000122","CDM","420","RC","97116","HCPCS",,,"facility","outpatient",,,"GP","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT THERAPEUTIC MASSAGE EA 15 MIN","17000123","CDM","420","RC","97124","HCPCS",,,"facility","inpatient",,,"GP","171","171",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT THERAPEUTIC MASSAGE EA 15 MIN","17000123","CDM","420","RC","97124","HCPCS",,,"facility","outpatient",,,"GP","171","171",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT MANUAL THERAPY EA 15 MIN","17000124","CDM","420","RC","97140","HCPCS",,,"facility","inpatient",,,"GP","246","246",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT MANUAL THERAPY EA 15 MIN","17000124","CDM","420","RC","97140","HCPCS",,,"facility","outpatient",,,"GP","246","246",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT THERAPEUTIC ACTIVITY EA 15 MIN","17000126","CDM","420","RC","97530","HCPCS",,,"facility","inpatient",,,"GP","253","253",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT THERAPEUTIC ACTIVITY EA 15 MIN","17000126","CDM","420","RC","97530","HCPCS",,,"facility","outpatient",,,"GP","253","253",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT SENSORY INTEGRATION EA 15 MIN","17000128","CDM","420","RC","97533","HCPCS",,,"facility","inpatient",,,"GP","135","135",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT SENSORY INTEGRATION EA 15 MIN","17000128","CDM","420","RC","97533","HCPCS",,,"facility","outpatient",,,"GP","135","135",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT ADL TRAINING EA 15 MIN","17000129","CDM","420","RC","97535","HCPCS",,,"facility","inpatient",,,"GP","240","240",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT ADL TRAINING EA 15 MIN","17000129","CDM","420","RC","97535","HCPCS",,,"facility","outpatient",,,"GP","240","240",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT COMMUNITY REINTEGRATION EA 15 MIN","17000130","CDM","420","RC","97537","HCPCS",,,"facility","inpatient",,,"GP","148","148",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT COMMUNITY REINTEGRATION EA 15 MIN","17000130","CDM","420","RC","97537","HCPCS",,,"facility","outpatient",,,"GP","148","148",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT WHEELCHAIR TRAINING EA 15 MIN","17000131","CDM","420","RC","97542","HCPCS",,,"facility","inpatient",,,"GP","200","200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT WHEELCHAIR TRAINING EA 15 MIN","17000131","CDM","420","RC","97542","HCPCS",,,"facility","outpatient",,,"GP","200","200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT WORK CONDITIONING ADD 60 MIN","17000133","CDM","420","RC","97546","HCPCS",,,"facility","inpatient",,,"GP","507","507",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT WORK CONDITIONING ADD 60 MIN","17000133","CDM","420","RC","97546","HCPCS",,,"facility","outpatient",,,"GP","507","507",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT PHYSICAL PERFORMANCE TEST EA 15 MIN","17000139","CDM","420","RC","97750","HCPCS",,,"facility","inpatient",,,"GP","192","192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT PHYSICAL PERFORMANCE TEST EA 15 MIN","17000139","CDM","420","RC","97750","HCPCS",,,"facility","outpatient",,,"GP","192","192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT ORTHOTIC TRAINING INITIAL EA 15 MIN","17000141","CDM","420","RC","97760","HCPCS",,,"facility","inpatient",,,"GP","221","221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT ORTHOTIC TRAINING INITIAL EA 15 MIN","17000141","CDM","420","RC","97760","HCPCS",,,"facility","outpatient",,,"GP","221","221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT PROSTHETIC TRAINING INITIAL EA 15 MIN","17000142","CDM","420","RC","97761","HCPCS",,,"facility","inpatient",,,"GP","191","191",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT PROSTHETIC TRAINING INITIAL EA 15 MIN","17000142","CDM","420","RC","97761","HCPCS",,,"facility","outpatient",,,"GP","191","191",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT MCAL SINGLE MODAL INIT 30","17000292","CDM",,,,,,,"facility","inpatient",,,,"454","454",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT MCAL SINGLE MODAL INIT 30","17000292","CDM",,,,,,,"facility","outpatient",,,,"454","454",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PT WORK COND INIT 120","17000318","CDM","420","RC","97545","HCPCS",,,"facility","inpatient",,,"GP","1071","1071",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT WORK COND INIT 120","17000318","CDM","420","RC","97545","HCPCS",,,"facility","outpatient",,,"GP","1071","1071",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT APP LONG ARM CAST","17000329","CDM","420","RC","29065","HCPCS",,,"facility","inpatient",,,"GP","682","682",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT APP LONG ARM CAST","17000329","CDM","420","RC","29065","HCPCS",,,"facility","outpatient",,,"GP","682","682",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT APP LONG LEG CYLINDER","17000330","CDM","420","RC","29365","HCPCS",,,"facility","inpatient",,,"GP","977","977",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT APP LONG LEG CYLINDER","17000330","CDM","420","RC","29365","HCPCS",,,"facility","outpatient",,,"GP","977","977",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT CANALITH REPOSITIONING","17000536","CDM","420","RC","95992","HCPCS",,,"facility","inpatient",,,"GP","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT CANALITH REPOSITIONING","17000536","CDM","420","RC","95992","HCPCS",,,"facility","outpatient",,,"GP","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT EVAL LOW COMPLEXITY","17000568","CDM","424","RC","97161","HCPCS",,,"facility","inpatient",,,"GP","495","495",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT EVAL LOW COMPLEXITY","17000568","CDM","424","RC","97161","HCPCS",,,"facility","outpatient",,,"GP","495","495",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT RE-EVAL ESTABLISHED PLAN CARE","17000571","CDM","424","RC","97164","HCPCS",,,"facility","inpatient",,,"GP","330","330",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT RE-EVAL ESTABLISHED PLAN CARE","17000571","CDM","424","RC","97164","HCPCS",,,"facility","outpatient",,,"GP","330","330",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG OT EVAL LOW COMPLEXITY","17000572","CDM","434","RC","97165","HCPCS",,,"facility","inpatient",,,"GO","508","508",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT EVAL LOW COMPLEXITY","17000572","CDM","434","RC","97165","HCPCS",,,"facility","outpatient",,,"GO","508","508",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT RE-EVAL ESTABLISHED PLAN CARE","17000575","CDM","434","RC","97168","HCPCS",,,"facility","inpatient",,,"GO","372","372",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT RE-EVAL ESTABLISHED PLAN CARE","17000575","CDM","434","RC","97168","HCPCS",,,"facility","outpatient",,,"GO","372","372",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG PT ORTHC/PROSTC MGMT SBSQ ENC","17000582","CDM","420","RC","97763","HCPCS",,,"facility","inpatient",,,"GP","243","243",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT ORTHC/PROSTC MGMT SBSQ ENC","17000582","CDM","420","RC","97763","HCPCS",,,"facility","outpatient",,,"GP","243","243",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT MECH TRACT","17000596","CDM","420","RC","97012","HCPCS",,,"facility","inpatient",,,"GP","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT MECH TRACT","17000596","CDM","420","RC","97012","HCPCS",,,"facility","outpatient",,,"GP","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT PARAFFIN BATH","17000598","CDM","420","RC","97018","HCPCS",,,"facility","inpatient",,,"GP","141","141",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT PARAFFIN BATH","17000598","CDM","420","RC","97018","HCPCS",,,"facility","outpatient",,,"GP","141","141",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT WHIRLPOOL","17000599","CDM","420","RC","97022","HCPCS",,,"facility","inpatient",,,"GP","141","141",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT WHIRLPOOL","17000599","CDM","420","RC","97022","HCPCS",,,"facility","outpatient",,,"GP","141","141",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT PROC THER GP","17000601","CDM","420","RC","97150","HCPCS",,,"facility","inpatient",,,"GP","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT PROC THER GP","17000601","CDM","420","RC","97150","HCPCS",,,"facility","outpatient",,,"GP","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT E-STIM SUPERVISED","17000604","CDM","420","RC","G0283","HCPCS",,,"facility","inpatient",,,"GP","161","161",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT E-STIM SUPERVISED","17000604","CDM","420","RC","G0283","HCPCS",,,"facility","outpatient",,,"GP","161","161",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT EVAL MOD COMPLEXITY","17000608","CDM","424","RC","97162","HCPCS",,,"facility","inpatient",,,"GP","558","558",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT EVAL MOD COMPLEXITY","17000608","CDM","424","RC","97162","HCPCS",,,"facility","outpatient",,,"GP","558","558",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT EVAL HIGH COMPLEXITY","17000609","CDM","424","RC","97163","HCPCS",,,"facility","inpatient",,,"GP","629","629",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT EVAL HIGH COMPLEXITY","17000609","CDM","424","RC","97163","HCPCS",,,"facility","outpatient",,,"GP","629","629",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT DEVEL TST PHYS/QHP 1ST HR","17000610","CDM","420","RC","96112","HCPCS",,,"facility","inpatient",,,"GP","842","842",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT DEVEL TST PHYS/QHP 1ST HR","17000610","CDM","420","RC","96112","HCPCS",,,"facility","outpatient",,,"GP","842","842",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT DEVEL TST PHYS/QHP EA ADDL 30 MIN","17000611","CDM","420","RC","96113","HCPCS",,,"facility","inpatient",,,"GP","431","431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT DEVEL TST PHYS/QHP EA ADDL 30 MIN","17000611","CDM","420","RC","96113","HCPCS",,,"facility","outpatient",,,"GP","431","431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG TH PT MCAL SINGLE MODALITY ADDITIONAL 15 MIN","17000616","CDM",,,,,,,"facility","inpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL SINGLE MODALITY ADDITIONAL 15 MIN","17000616","CDM",,,,,,,"facility","outpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL SINGLE PROCURE INITIAL 30 MIN","17000617","CDM",,,,,,,"facility","inpatient",,,,"629","629",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL SINGLE PROCURE INITIAL 30 MIN","17000617","CDM",,,,,,,"facility","outpatient",,,,"629","629",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL SINGLE PROCURE ADDITIONAL 15 MIN","17000618","CDM",,,,,,,"facility","inpatient",,,,"324","324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL SINGLE PROCURE ADDITIONAL 15 MIN","17000618","CDM",,,,,,,"facility","outpatient",,,,"324","324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL TREAT COMBO INIT 30","17000619","CDM",,,,,,,"facility","inpatient",,,,"520","520",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL TREAT COMBO INIT 30","17000619","CDM",,,,,,,"facility","outpatient",,,,"520","520",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL TX COMB PROC/MODALITIES ADDL 15 MN","17000620","CDM",,,,,,,"facility","inpatient",,,,"263","263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL TX COMB PROC/MODALITIES ADDL 15 MN","17000620","CDM",,,,,,,"facility","outpatient",,,,"263","263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL EVALUATION INITIAL 30 MIN","17000623","CDM",,,,,,,"facility","inpatient",,,,"497","497",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL EVALUATION INITIAL 30 MIN","17000623","CDM",,,,,,,"facility","outpatient",,,,"497","497",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL RE-EVALUATION INITIAL 30 MIN","17000624","CDM",,,,,,,"facility","inpatient",,,,"404","404",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL RE-EVALUATION INITIAL 30 MIN","17000624","CDM",,,,,,,"facility","outpatient",,,,"404","404",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL EVALUATION ADDITIONAL 15 MIN","17000625","CDM",,,,,,,"facility","inpatient",,,,"294","294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL EVALUATION ADDITIONAL 15 MIN","17000625","CDM",,,,,,,"facility","outpatient",,,,"294","294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL RE-EVALUATION ADDITIONAL 15 MIN","17000626","CDM",,,,,,,"facility","inpatient",,,,"253","253",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL RE-EVALUATION ADDITIONAL 15 MIN","17000626","CDM",,,,,,,"facility","outpatient",,,,"253","253",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT THERAPEUTIC EXERCISE EA 15 MIN","17000627","CDM","420","RC","97110","HCPCS",,,"facility","inpatient",,,"GP,95","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT THERAPEUTIC EXERCISE EA 15 MIN","17000627","CDM","420","RC","97110","HCPCS",,,"facility","outpatient",,,"GP,95","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT NEUROMUSCULAR REEDUCATION EA 15 MIN","17000628","CDM","420","RC","97112","HCPCS",,,"facility","inpatient",,,"GP,95","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT NEUROMUSCULAR REEDUCATION EA 15 MIN","17000628","CDM","420","RC","97112","HCPCS",,,"facility","outpatient",,,"GP,95","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT GAIT TRAINING EA 15 MIN","17000629","CDM","420","RC","97116","HCPCS",,,"facility","inpatient",,,"GP,95","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT GAIT TRAINING EA 15 MIN","17000629","CDM","420","RC","97116","HCPCS",,,"facility","outpatient",,,"GP,95","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT THERAPEUTIC ACTIVITY EA 15 MIN","17000630","CDM","420","RC","97530","HCPCS",,,"facility","inpatient",,,"GP,95","253","253",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT THERAPEUTIC ACTIVITY EA 15 MIN","17000630","CDM","420","RC","97530","HCPCS",,,"facility","outpatient",,,"GP,95","253","253",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT ADL TRAINING EA 15 MIN","17000631","CDM","420","RC","97535","HCPCS",,,"facility","inpatient",,,"GP,95","240","240",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT ADL TRAINING EA 15 MIN","17000631","CDM","420","RC","97535","HCPCS",,,"facility","outpatient",,,"GP,95","240","240",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT MCAL SINGLE MODAL INIT 30","17000632","CDM",,,,,,,"facility","inpatient",,,,"483","483",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT MCAL SINGLE MODAL INIT 30","17000632","CDM",,,,,,,"facility","outpatient",,,,"483","483",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PT EVAL LOW COMPLEXITY","17000633","CDM","424","RC","97161","HCPCS",,,"facility","inpatient",,,"GP,95","495","495",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT EVAL LOW COMPLEXITY","17000633","CDM","424","RC","97161","HCPCS",,,"facility","outpatient",,,"GP,95","495","495",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT RE-EVAL ESTABLISHED PLAN CARE","17000634","CDM","424","RC","97164","HCPCS",,,"facility","inpatient",,,"GP,95","330","330",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT RE-EVAL ESTABLISHED PLAN CARE","17000634","CDM","424","RC","97164","HCPCS",,,"facility","outpatient",,,"GP,95","330","330",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT PROC THER GP","17000635","CDM","420","RC","97150","HCPCS",,,"facility","inpatient",,,"GP,95","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT PROC THER GP","17000635","CDM","420","RC","97150","HCPCS",,,"facility","outpatient",,,"GP,95","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT EVAL MOD COMPLEXITY","17000636","CDM","424","RC","97162","HCPCS",,,"facility","inpatient",,,"GP,95","558","558",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT EVAL MOD COMPLEXITY","17000636","CDM","424","RC","97162","HCPCS",,,"facility","outpatient",,,"GP,95","558","558",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT EVAL HIGH COMPLEXITY","17000637","CDM","424","RC","97163","HCPCS",,,"facility","inpatient",,,"GP,95","629","629",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT EVAL HIGH COMPLEXITY","17000637","CDM","424","RC","97163","HCPCS",,,"facility","outpatient",,,"GP,95","629","629",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT DEVEL TST PHYS/QHP 1ST HR","17000638","CDM","420","RC","96112","HCPCS",,,"facility","inpatient",,,"GP,95","842","842",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT DEVEL TST PHYS/QHP 1ST HR","17000638","CDM","420","RC","96112","HCPCS",,,"facility","outpatient",,,"GP,95","842","842",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT DEVEL TST PHYS/QHP EA ADDL 30 MIN","17000639","CDM","420","RC","96113","HCPCS",,,"facility","inpatient",,,"GP,95","431","431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT DEVEL TST PHYS/QHP EA ADDL 30 MIN","17000639","CDM","420","RC","96113","HCPCS",,,"facility","outpatient",,,"GP,95","431","431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT WHEELCHAIR TRAINING EA 15 MIN","17000641","CDM","420","RC","97542","HCPCS",,,"facility","inpatient",,,"GP,95","200","200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT WHEELCHAIR TRAINING EA 15 MIN","17000641","CDM","420","RC","97542","HCPCS",,,"facility","outpatient",,,"GP,95","200","200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT PHYSICAL PERFORMANCE TEST EA 15 MIN","17000642","CDM","420","RC","97750","HCPCS",,,"facility","inpatient",,,"GP,95","192","192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT PHYSICAL PERFORMANCE TEST EA 15 MIN","17000642","CDM","420","RC","97750","HCPCS",,,"facility","outpatient",,,"GP,95","192","192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT ORTHOTIC TRAINING INITIAL EA 15 MIN","17000643","CDM","420","RC","97760","HCPCS",,,"facility","inpatient",,,"GP,95","221","221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT ORTHOTIC TRAINING INITIAL EA 15 MIN","17000643","CDM","420","RC","97760","HCPCS",,,"facility","outpatient",,,"GP,95","221","221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT PROSTHETIC TRAINING INITIAL EA 15 MIN","17000644","CDM","420","RC","97761","HCPCS",,,"facility","inpatient",,,"GP,95","191","191",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PT PROSTHETIC TRAINING INITIAL EA 15 MIN","17000644","CDM","420","RC","97761","HCPCS",,,"facility","outpatient",,,"GP,95","191","191",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG PT LOW LVL LASER FOR POST OP PAIN","17000649","CDM","420","RC","97037","HCPCS",,,"facility","inpatient",,,"GP","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT LOW LVL LASER FOR POST OP PAIN","17000649","CDM","420","RC","97037","HCPCS",,,"facility","outpatient",,,"GP","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT CAREGIVER TRAINING 1ST 30 MIN","17000650","CDM","420","RC","97550","HCPCS",,,"facility","inpatient",,,"GP","471","471",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT CAREGIVER TRAINING 1ST 30 MIN","17000650","CDM","420","RC","97550","HCPCS",,,"facility","outpatient",,,"GP","471","471",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT CAREGIVER TRAINING EA ADDL 15 MIN","17000651","CDM","420","RC","97551","HCPCS",,,"facility","inpatient",,,"GP","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT CAREGIVER TRAINING EA ADDL 15 MIN","17000651","CDM","420","RC","97551","HCPCS",,,"facility","outpatient",,,"GP","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT GROUP CAREGIVER TRAINING","17000652","CDM","420","RC","97552","HCPCS",,,"facility","inpatient",,,"GP","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG PT GROUP CAREGIVER TRAINING","17000652","CDM","420","RC","97552","HCPCS",,,"facility","outpatient",,,"GP","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GP: Services delivered under an outpatient physical therapy plan of care"
"HCHG OT MCAL EVALUATION INITIAL 30 MIN","17200062","CDM",,,,,,,"facility","inpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL EVALUATION INITIAL 30 MIN","17200062","CDM",,,,,,,"facility","outpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL RE-EVALUATION INITIAL 30 MIN","17200063","CDM",,,,,,,"facility","inpatient",,,,"464","464",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL RE-EVALUATION INITIAL 30 MIN","17200063","CDM",,,,,,,"facility","outpatient",,,,"464","464",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL EVALUATION ADDITIONAL 15 MIN","17200065","CDM",,,,,,,"facility","inpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL EVALUATION ADDITIONAL 15 MIN","17200065","CDM",,,,,,,"facility","outpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL RE-EVALUATION ADDITIONAL 15 MIN","17200066","CDM",,,,,,,"facility","inpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL RE-EVALUATION ADDITIONAL 15 MIN","17200066","CDM",,,,,,,"facility","outpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT APPLICATION SPLINT FINGER STATIC","17200077","CDM","430","RC","29130","HCPCS",,,"facility","inpatient",,,"GO","536","536",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT APPLICATION SPLINT FINGER STATIC","17200077","CDM","430","RC","29130","HCPCS",,,"facility","outpatient",,,"GO","536","536",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT STRAP SHOULDER","17200079","CDM","430","RC","29240","HCPCS",,,"facility","inpatient",,,"GO","433","433",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT STRAP SHOULDER","17200079","CDM","430","RC","29240","HCPCS",,,"facility","outpatient",,,"GO","433","433",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ELECTRICAL STIMULATION ATTENDED EA 15 MIN","17200100","CDM","430","RC","97032","HCPCS",,,"facility","inpatient",,,"GO","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ELECTRICAL STIMULATION ATTENDED EA 15 MIN","17200100","CDM","430","RC","97032","HCPCS",,,"facility","outpatient",,,"GO","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT IONTOPHORESIS EA 15 MIN","17200101","CDM","430","RC","97033","HCPCS",,,"facility","inpatient",,,"GO","158","158",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT IONTOPHORESIS EA 15 MIN","17200101","CDM","430","RC","97033","HCPCS",,,"facility","outpatient",,,"GO","158","158",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT CONTRAST BATHS EA 15 MIN","17200102","CDM","430","RC","97034","HCPCS",,,"facility","inpatient",,,"GO","123","123",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT CONTRAST BATHS EA 15 MIN","17200102","CDM","430","RC","97034","HCPCS",,,"facility","outpatient",,,"GO","123","123",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ULTRASOUND EA 15 MIN","17200103","CDM","430","RC","97035","HCPCS",,,"facility","inpatient",,,"GO","162","162",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ULTRASOUND EA 15 MIN","17200103","CDM","430","RC","97035","HCPCS",,,"facility","outpatient",,,"GO","162","162",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT THERAPEUTIC EXERCISE EA 15 MIN","17200104","CDM","430","RC","97110","HCPCS",,,"facility","inpatient",,,"GO","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT THERAPEUTIC EXERCISE EA 15 MIN","17200104","CDM","430","RC","97110","HCPCS",,,"facility","outpatient",,,"GO","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT NEUROMUSCULAR REEDUCATION EA 15 MIN","17200105","CDM","430","RC","97112","HCPCS",,,"facility","inpatient",,,"GO","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT NEUROMUSCULAR REEDUCATION EA 15 MIN","17200105","CDM","430","RC","97112","HCPCS",,,"facility","outpatient",,,"GO","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT AQUATIC THERAPY EA 15 MIN","17200106","CDM","430","RC","97113","HCPCS",,,"facility","inpatient",,,"GO","243","243",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT AQUATIC THERAPY EA 15 MIN","17200106","CDM","430","RC","97113","HCPCS",,,"facility","outpatient",,,"GO","243","243",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT THERAPEUTIC MASSAGE EA 15 MIN","17200107","CDM","430","RC","97124","HCPCS",,,"facility","inpatient",,,"GO","171","171",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT THERAPEUTIC MASSAGE EA 15 MIN","17200107","CDM","430","RC","97124","HCPCS",,,"facility","outpatient",,,"GO","171","171",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT MANUAL THERAPY EA 15 MIN","17200108","CDM","430","RC","97140","HCPCS",,,"facility","inpatient",,,"GO","246","246",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT MANUAL THERAPY EA 15 MIN","17200108","CDM","430","RC","97140","HCPCS",,,"facility","outpatient",,,"GO","246","246",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT THERAPEUTIC ACTIVITY EA 15 MIN","17200110","CDM","430","RC","97530","HCPCS",,,"facility","inpatient",,,"GO","253","253",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT THERAPEUTIC ACTIVITY EA 15 MIN","17200110","CDM","430","RC","97530","HCPCS",,,"facility","outpatient",,,"GO","253","253",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT SENSORY INTEGRATION EA 15 MIN","17200112","CDM","430","RC","97533","HCPCS",,,"facility","inpatient",,,"GO","135","135",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT SENSORY INTEGRATION EA 15 MIN","17200112","CDM","430","RC","97533","HCPCS",,,"facility","outpatient",,,"GO","135","135",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ADL TRAINING EA 15 MIN","17200113","CDM","430","RC","97535","HCPCS",,,"facility","inpatient",,,"GO","240","240",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ADL TRAINING EA 15 MIN","17200113","CDM","430","RC","97535","HCPCS",,,"facility","outpatient",,,"GO","240","240",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT COMMUNITY REINTEGRATION EA 15 MIN","17200114","CDM","430","RC","97537","HCPCS",,,"facility","inpatient",,,"GO","148","148",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT COMMUNITY REINTEGRATION EA 15 MIN","17200114","CDM","430","RC","97537","HCPCS",,,"facility","outpatient",,,"GO","148","148",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT WHEELCHAIR TRAINING EA 15 MIN","17200115","CDM","430","RC","97542","HCPCS",,,"facility","inpatient",,,"GO","200","200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT WHEELCHAIR TRAINING EA 15 MIN","17200115","CDM","430","RC","97542","HCPCS",,,"facility","outpatient",,,"GO","200","200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT WORK CONDITIONING INITIAL 120 MIN","17200116","CDM","430","RC","97545","HCPCS",,,"facility","inpatient",,,"GO","1021","1021",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT WORK CONDITIONING INITIAL 120 MIN","17200116","CDM","430","RC","97545","HCPCS",,,"facility","outpatient",,,"GO","1021","1021",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT WORK CONDITIONING ADD 60 MIN","17200117","CDM","430","RC","97546","HCPCS",,,"facility","inpatient",,,"GO","483","483",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT WORK CONDITIONING ADD 60 MIN","17200117","CDM","430","RC","97546","HCPCS",,,"facility","outpatient",,,"GO","483","483",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT PHYSICAL PERFORMANCE TEST EA 15 MIN","17200121","CDM","430","RC","97750","HCPCS",,,"facility","inpatient",,,"GO","192","192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT PHYSICAL PERFORMANCE TEST EA 15 MIN","17200121","CDM","430","RC","97750","HCPCS",,,"facility","outpatient",,,"GO","192","192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ASSISTIVE TECHNOLOGIES ASSESSMENT EA 15 MIN","17200122","CDM","430","RC","97755","HCPCS",,,"facility","inpatient",,,"GO","204","204",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ASSISTIVE TECHNOLOGIES ASSESSMENT EA 15 MIN","17200122","CDM","430","RC","97755","HCPCS",,,"facility","outpatient",,,"GO","204","204",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ORTHOTIC TRAINING INITIAL EA 15 MIN","17200123","CDM","430","RC","97760","HCPCS",,,"facility","inpatient",,,"GO","221","221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ORTHOTIC TRAINING INITIAL EA 15 MIN","17200123","CDM","430","RC","97760","HCPCS",,,"facility","outpatient",,,"GO","221","221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT PROSTHETIC TRAINING INITIAL EA 15 MIN","17200124","CDM","430","RC","97761","HCPCS",,,"facility","inpatient",,,"GO","191","191",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT PROSTHETIC TRAINING INITIAL EA 15 MIN","17200124","CDM","430","RC","97761","HCPCS",,,"facility","outpatient",,,"GO","191","191",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT MCAL TX ADTL 15 MIN","17200139","CDM",,,,,,,"facility","inpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL TX ADTL 15 MIN","17200139","CDM",,,,,,,"facility","outpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL TREAT INIT 30","17200284","CDM",,,,,,,"facility","inpatient",,,,"478","478",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL TREAT INIT 30","17200284","CDM",,,,,,,"facility","outpatient",,,,"478","478",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL COMBO MODAL ADD 15","17200296","CDM",,,,,,,"facility","inpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL COMBO MODAL ADD 15","17200296","CDM",,,,,,,"facility","outpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL COMBO MODAL INIT 30","17200310","CDM",,,,,,,"facility","inpatient",,,,"507","507",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT MCAL COMBO MODAL INIT 30","17200310","CDM",,,,,,,"facility","outpatient",,,,"507","507",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT COGNTVE TEST BY HC PRO","17200330","CDM","430","RC","96125","HCPCS",,,"facility","inpatient",,,"GO","577","577",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT COGNTVE TEST BY HC PRO","17200330","CDM","430","RC","96125","HCPCS",,,"facility","outpatient",,,"GO","577","577",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ORTHC/PROSTC MGMT SBSQ ENC","17200493","CDM","430","RC","97763","HCPCS",,,"facility","inpatient",,,"GO","243","243",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ORTHC/PROSTC MGMT SBSQ ENC","17200493","CDM","430","RC","97763","HCPCS",,,"facility","outpatient",,,"GO","243","243",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT TX SWALL/ORAL FNX","17200498","CDM","430","RC","92526","HCPCS",,,"facility","inpatient",,,"GO","539","539",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT TX SWALL/ORAL FNX","17200498","CDM","430","RC","92526","HCPCS",,,"facility","outpatient",,,"GO","539","539",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT EVAL FNX SWALL","17200499","CDM","434","RC","92610","HCPCS",,,"facility","inpatient",,,"GO","826","826",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT EVAL FNX SWALL","17200499","CDM","434","RC","92610","HCPCS",,,"facility","outpatient",,,"GO","826","826",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ROM BODY WO HAND","17200505","CDM","430","RC","95851","HCPCS",,,"facility","inpatient",,,"GO","474","474",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ROM BODY WO HAND","17200505","CDM","430","RC","95851","HCPCS",,,"facility","outpatient",,,"GO","474","474",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ROM HAND","17200506","CDM","430","RC","95852","HCPCS",,,"facility","inpatient",,,"GO","312","312",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT ROM HAND","17200506","CDM","430","RC","95852","HCPCS",,,"facility","outpatient",,,"GO","312","312",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT PARAFFIN BATH","17200509","CDM","430","RC","97018","HCPCS",,,"facility","inpatient",,,"GO","141","141",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT PARAFFIN BATH","17200509","CDM","430","RC","97018","HCPCS",,,"facility","outpatient",,,"GO","141","141",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT WHIRLPOOL","17200510","CDM","430","RC","97022","HCPCS",,,"facility","inpatient",,,"GO","141","141",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT WHIRLPOOL","17200510","CDM","430","RC","97022","HCPCS",,,"facility","outpatient",,,"GO","141","141",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT GROUP THERAPY","17200512","CDM","430","RC","97150","HCPCS",,,"facility","inpatient",,,"GO","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT GROUP THERAPY","17200512","CDM","430","RC","97150","HCPCS",,,"facility","outpatient",,,"GO","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT DEBRIDE NON-SELECT","17200513","CDM","430","RC","97602","HCPCS",,,"facility","inpatient",,,"GO","501","501",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT DEBRIDE NON-SELECT","17200513","CDM","430","RC","97602","HCPCS",,,"facility","outpatient",,,"GO","501","501",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT E-STIM SUPERVISED","17200514","CDM","430","RC","G0283","HCPCS",,,"facility","inpatient",,,"GO","161","161",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT E-STIM SUPERVISED","17200514","CDM","430","RC","G0283","HCPCS",,,"facility","outpatient",,,"GO","161","161",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT EVAL MOD COMPLEXITY","17200516","CDM","434","RC","97166","HCPCS",,,"facility","inpatient",,,"GO","624","624",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT EVAL MOD COMPLEXITY","17200516","CDM","434","RC","97166","HCPCS",,,"facility","outpatient",,,"GO","624","624",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT EVAL HIGH COMPLEXITY","17200517","CDM","434","RC","97167","HCPCS",,,"facility","inpatient",,,"GO","646","646",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT EVAL HIGH COMPLEXITY","17200517","CDM","434","RC","97167","HCPCS",,,"facility","outpatient",,,"GO","646","646",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT DEVEL TST PHYS/QHP 1ST HR","17200518","CDM","430","RC","96112","HCPCS",,,"facility","inpatient",,,"GO","842","842",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT DEVEL TST PHYS/QHP 1ST HR","17200518","CDM","430","RC","96112","HCPCS",,,"facility","outpatient",,,"GO","842","842",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT DEVEL TST PHYS/QHP EA ADDL 30 MIN","17200519","CDM","430","RC","96113","HCPCS",,,"facility","inpatient",,,"GO","431","431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT DEVEL TST PHYS/QHP EA ADDL 30 MIN","17200519","CDM","430","RC","96113","HCPCS",,,"facility","outpatient",,,"GO","431","431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG COGNTIVE FNCTN INTRVEN 1ST 15 MIN","17200520","CDM","430","RC","97129","HCPCS",,,"facility","inpatient",,,"GO","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG COGNTIVE FNCTN INTRVEN 1ST 15 MIN","17200520","CDM","430","RC","97129","HCPCS",,,"facility","outpatient",,,"GO","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","17200521","CDM","430","RC","97130","HCPCS",,,"facility","inpatient",,,"GO","168","168",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","17200521","CDM","430","RC","97130","HCPCS",,,"facility","outpatient",,,"GO","168","168",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG TH OT EVAL LOW COMPLEXITY","17200524","CDM","434","RC","97165","HCPCS",,,"facility","inpatient",,,"GO,95","508","508",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT EVAL LOW COMPLEXITY","17200524","CDM","434","RC","97165","HCPCS",,,"facility","outpatient",,,"GO,95","508","508",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT RE-EVAL ESTABLISHED PLAN CARE","17200525","CDM","434","RC","97168","HCPCS",,,"facility","inpatient",,,"GO,95","372","372",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT RE-EVAL ESTABLISHED PLAN CARE","17200525","CDM","434","RC","97168","HCPCS",,,"facility","outpatient",,,"GO,95","372","372",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT MCAL EVALUATION INITIAL 30 MIN","17200526","CDM",,,,,,,"facility","inpatient",,,,"565","565",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL EVALUATION INITIAL 30 MIN","17200526","CDM",,,,,,,"facility","outpatient",,,,"565","565",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL EVALUATION ADDITIONAL 15 MIN","17200528","CDM",,,,,,,"facility","inpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL EVALUATION ADDITIONAL 15 MIN","17200528","CDM",,,,,,,"facility","outpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT THERAPEUTIC EXERCISE EA 15 MIN","17200530","CDM","430","RC","97110","HCPCS",,,"facility","inpatient",,,"GO,95","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT THERAPEUTIC EXERCISE EA 15 MIN","17200530","CDM","430","RC","97110","HCPCS",,,"facility","outpatient",,,"GO,95","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT NEUROMUSCULAR REEDUCATION EA 15 MIN","17200531","CDM","430","RC","97112","HCPCS",,,"facility","inpatient",,,"GO,95","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT NEUROMUSCULAR REEDUCATION EA 15 MIN","17200531","CDM","430","RC","97112","HCPCS",,,"facility","outpatient",,,"GO,95","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT THERAPEUTIC ACTIVITY EA 15 MIN","17200532","CDM","430","RC","97530","HCPCS",,,"facility","inpatient",,,"GO,95","253","253",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT THERAPEUTIC ACTIVITY EA 15 MIN","17200532","CDM","430","RC","97530","HCPCS",,,"facility","outpatient",,,"GO,95","253","253",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT ADL TRAINING EA 15 MIN","17200533","CDM","430","RC","97535","HCPCS",,,"facility","inpatient",,,"GO,95","240","240",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT ADL TRAINING EA 15 MIN","17200533","CDM","430","RC","97535","HCPCS",,,"facility","outpatient",,,"GO,95","240","240",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT MCAL TX ADTL 15 MIN","17200534","CDM",,,,,,,"facility","inpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL TX ADTL 15 MIN","17200534","CDM",,,,,,,"facility","outpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL TREAT INIT 30","17200535","CDM",,,,,,,"facility","inpatient",,,,"504","504",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL TREAT INIT 30","17200535","CDM",,,,,,,"facility","outpatient",,,,"504","504",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL COMBO MODAL ADD 15","17200536","CDM",,,,,,,"facility","inpatient",,,,"259","259",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL COMBO MODAL ADD 15","17200536","CDM",,,,,,,"facility","outpatient",,,,"259","259",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL COMBO MODAL INIT 30","17200537","CDM",,,,,,,"facility","inpatient",,,,"524","524",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT MCAL COMBO MODAL INIT 30","17200537","CDM",,,,,,,"facility","outpatient",,,,"524","524",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OT GROUP THERAPY","17200538","CDM","430","RC","97150","HCPCS",,,"facility","inpatient",,,"GO,95","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT GROUP THERAPY","17200538","CDM","430","RC","97150","HCPCS",,,"facility","outpatient",,,"GO,95","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT EVAL MOD COMPLEXITY","17200539","CDM","434","RC","97166","HCPCS",,,"facility","inpatient",,,"GO,95","624","624",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT EVAL MOD COMPLEXITY","17200539","CDM","434","RC","97166","HCPCS",,,"facility","outpatient",,,"GO,95","624","624",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT EVAL HIGH COMPLEXITY","17200540","CDM","434","RC","97167","HCPCS",,,"facility","inpatient",,,"GO,95","646","646",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT EVAL HIGH COMPLEXITY","17200540","CDM","434","RC","97167","HCPCS",,,"facility","outpatient",,,"GO,95","646","646",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT DEVEL TST PHYS/QHP 1ST HR","17200541","CDM","430","RC","96112","HCPCS",,,"facility","inpatient",,,"GO,95","842","842",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT DEVEL TST PHYS/QHP 1ST HR","17200541","CDM","430","RC","96112","HCPCS",,,"facility","outpatient",,,"GO,95","842","842",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT DEVEL TST PHYS/QHP EA ADDL 30 MIN","17200542","CDM","430","RC","96113","HCPCS",,,"facility","inpatient",,,"GO,95","431","431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT DEVEL TST PHYS/QHP EA ADDL 30 MIN","17200542","CDM","430","RC","96113","HCPCS",,,"facility","outpatient",,,"GO,95","431","431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT WHEELCHAIR TRAINING EA 15 MIN","17200543","CDM","430","RC","97542","HCPCS",,,"facility","inpatient",,,"GO,95","200","200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT WHEELCHAIR TRAINING EA 15 MIN","17200543","CDM","430","RC","97542","HCPCS",,,"facility","outpatient",,,"GO,95","200","200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT PHYSICAL PERFORMANCE TEST EA 15 MIN","17200544","CDM","430","RC","97750","HCPCS",,,"facility","inpatient",,,"GO,95","192","192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT PHYSICAL PERFORMANCE TEST EA 15 MIN","17200544","CDM","430","RC","97750","HCPCS",,,"facility","outpatient",,,"GO,95","192","192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT ORTHOTIC TRAINING INITIAL EA 15 MIN","17200545","CDM","430","RC","97760","HCPCS",,,"facility","inpatient",,,"GO,95","221","221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT ORTHOTIC TRAINING INITIAL EA 15 MIN","17200545","CDM","430","RC","97760","HCPCS",,,"facility","outpatient",,,"GO,95","221","221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT PROSTHETIC TRAINING INITIAL EA 15 MIN","17200546","CDM","430","RC","97761","HCPCS",,,"facility","inpatient",,,"GO,95","191","191",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT PROSTHETIC TRAINING INITIAL EA 15 MIN","17200546","CDM","430","RC","97761","HCPCS",,,"facility","outpatient",,,"GO,95","191","191",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT TX SWALL/ORAL FNX","17200551","CDM","430","RC","92526","HCPCS",,,"facility","inpatient",,,"GO,95","539","539",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT TX SWALL/ORAL FNX","17200551","CDM","430","RC","92526","HCPCS",,,"facility","outpatient",,,"GO,95","539","539",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT EVAL FNX SWALL","17200552","CDM","434","RC","92610","HCPCS",,,"facility","inpatient",,,"GO,95","826","826",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT EVAL FNX SWALL","17200552","CDM","434","RC","92610","HCPCS",,,"facility","outpatient",,,"GO,95","826","826",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT COGNTVE TEST BY HC PRO","17200553","CDM","430","RC","96125","HCPCS",,,"facility","inpatient",,,"GO,95","577","577",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT COGNTVE TEST BY HC PRO","17200553","CDM","430","RC","96125","HCPCS",,,"facility","outpatient",,,"GO,95","577","577",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT COGNTIVE FNCTN INTRVEN 1ST 15 MIN","17200554","CDM","430","RC","97129","HCPCS",,,"facility","inpatient",,,"GO,95","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT COGNTIVE FNCTN INTRVEN 1ST 15 MIN","17200554","CDM","430","RC","97129","HCPCS",,,"facility","outpatient",,,"GO,95","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","17200555","CDM","430","RC","97130","HCPCS",,,"facility","inpatient",,,"GO,95","168","168",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OT COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","17200555","CDM","430","RC","97130","HCPCS",,,"facility","outpatient",,,"GO,95","168","168",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG OT LOW LVL LASER FOR POST OP PAIN","17200556","CDM","430","RC","97037","HCPCS",,,"facility","inpatient",,,"GO","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT LOW LVL LASER FOR POST OP PAIN","17200556","CDM","430","RC","97037","HCPCS",,,"facility","outpatient",,,"GO","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT CAREGIVER TRAINING 1ST 30 MIN","17200557","CDM","430","RC","97550","HCPCS",,,"facility","inpatient",,,"GO","471","471",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT CAREGIVER TRAINING 1ST 30 MIN","17200557","CDM","430","RC","97550","HCPCS",,,"facility","outpatient",,,"GO","471","471",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT CAREGIVER TRAINING EA ADDL 15 MIN","17200558","CDM","430","RC","97551","HCPCS",,,"facility","inpatient",,,"GO","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT CAREGIVER TRAINING EA ADDL 15 MIN","17200558","CDM","430","RC","97551","HCPCS",,,"facility","outpatient",,,"GO","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT GROUP CAREGIVER TRAINING","17200559","CDM","430","RC","97552","HCPCS",,,"facility","inpatient",,,"GO","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT GROUP CAREGIVER TRAINING","17200559","CDM","430","RC","97552","HCPCS",,,"facility","outpatient",,,"GO","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT MOCA","17200563","CDM","430","RC","97799","HCPCS",,,"facility","inpatient",,,"GO","585","585",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG OT MOCA","17200563","CDM","430","RC","97799","HCPCS",,,"facility","outpatient",,,"GO","585","585",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GO: Services delivered under an outpatient occupational therapy plan of care"
"HCHG SP MCAL THERAPY SPEECH-LANG IND PER HOUR","17400005","CDM",,,,,,,"facility","inpatient",,,,"574","574",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SP MCAL THERAPY SPEECH-LANG IND PER HOUR","17400005","CDM",,,,,,,"facility","outpatient",,,,"574","574",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SP MCAL THERAPY SPEECH-LANG IND 1/2 HOUR","17400006","CDM",,,,,,,"facility","inpatient",,,,"478","478",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SP MCAL THERAPY SPEECH-LANG IND 1/2 HOUR","17400006","CDM",,,,,,,"facility","outpatient",,,,"478","478",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SP EVAL RX FOR NON SP GENERATIN DEVICE PRESCRIPTION","17400013","CDM","444","RC","92605","HCPCS",,,"facility","inpatient",,,"GN","886","886",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL RX FOR NON SP GENERATIN DEVICE PRESCRIPTION","17400013","CDM","444","RC","92605","HCPCS",,,"facility","outpatient",,,"GN","886","886",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL APHASIA HR","17400016","CDM","440","RC","96105","HCPCS",,,"facility","inpatient",,,"GN","668","668",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL APHASIA HR","17400016","CDM","440","RC","96105","HCPCS",,,"facility","outpatient",,,"GN","668","668",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP THER SVC NO SP/ALT DEV","17400021","CDM","440","RC","92606","HCPCS",,,"facility","inpatient",,,"GN","542","542",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP THER SVC NO SP/ALT DEV","17400021","CDM","440","RC","92606","HCPCS",,,"facility","outpatient",,,"GN","542","542",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL SP/COM DVC ADL 30","17400135","CDM","444","RC","92608","HCPCS",,,"facility","inpatient",,,"GN","129","129",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL SP/COM DVC ADL 30","17400135","CDM","444","RC","92608","HCPCS",,,"facility","outpatient",,,"GN","129","129",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL SP/COM DVC 1ST HR","17400137","CDM","444","RC","92607","HCPCS",,,"facility","inpatient",,,"GN","538","538",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL SP/COM DVC 1ST HR","17400137","CDM","444","RC","92607","HCPCS",,,"facility","outpatient",,,"GN","538","538",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP THER SVC SP DEVICE","17400138","CDM","440","RC","92609","HCPCS",,,"facility","inpatient",,,"GN","446","446",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP THER SVC SP DEVICE","17400138","CDM","440","RC","92609","HCPCS",,,"facility","outpatient",,,"GN","446","446",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP COGNTVE TEST BY HC PRO","17400139","CDM","440","RC","96125","HCPCS",,,"facility","inpatient",,,"GN","603","603",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP COGNTVE TEST BY HC PRO","17400139","CDM","440","RC","96125","HCPCS",,,"facility","outpatient",,,"GN","603","603",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP TX SP/LANG/COM IND","17400392","CDM","440","RC","92507","HCPCS",,,"facility","inpatient",,,"GN","578","578",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP TX SP/LANG/COM IND","17400392","CDM","440","RC","92507","HCPCS",,,"facility","outpatient",,,"GN","578","578",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP TX SP/LANG/COM GP","17400393","CDM","440","RC","92508","HCPCS",,,"facility","inpatient",,,"GN","170","170",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP TX SP/LANG/COM GP","17400393","CDM","440","RC","92508","HCPCS",,,"facility","outpatient",,,"GN","170","170",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG EVALUATION OF SPEECH FLUENCY","17400394","CDM","444","RC","92521","HCPCS",,,"facility","inpatient",,,"GN","573","573",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG EVALUATION OF SPEECH FLUENCY","17400394","CDM","444","RC","92521","HCPCS",,,"facility","outpatient",,,"GN","573","573",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG EVALUATE SPEECH PRODUCTION","17400395","CDM","444","RC","92522","HCPCS",,,"facility","inpatient",,,"GN","607","607",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG EVALUATE SPEECH PRODUCTION","17400395","CDM","444","RC","92522","HCPCS",,,"facility","outpatient",,,"GN","607","607",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG EVAL SPEECH SOUND LANG COMPREH","17400396","CDM","444","RC","92523","HCPCS",,,"facility","inpatient",,,"GN","803","803",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG EVAL SPEECH SOUND LANG COMPREH","17400396","CDM","444","RC","92523","HCPCS",,,"facility","outpatient",,,"GN","803","803",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP BEHAVRAL QUALIT ANALYS VOICE","17400397","CDM","440","RC","92524","HCPCS",,,"facility","inpatient",,,"GN","614","614",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP BEHAVRAL QUALIT ANALYS VOICE","17400397","CDM","440","RC","92524","HCPCS",,,"facility","outpatient",,,"GN","614","614",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP TX SWALL/ORAL FNX","17400398","CDM","440","RC","92526","HCPCS",,,"facility","inpatient",,,"GN","539","539",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP TX SWALL/ORAL FNX","17400398","CDM","440","RC","92526","HCPCS",,,"facility","outpatient",,,"GN","539","539",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL COM DEVICE","17400399","CDM","440","RC","92597","HCPCS",,,"facility","inpatient",,,"GN","670","670",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL COM DEVICE","17400399","CDM","440","RC","92597","HCPCS",,,"facility","outpatient",,,"GN","670","670",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL FNX SWALL","17400400","CDM","444","RC","92610","HCPCS",,,"facility","inpatient",,,"GN","826","826",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL FNX SWALL","17400400","CDM","444","RC","92610","HCPCS",,,"facility","outpatient",,,"GN","826","826",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL MTN FLUOR SWAL","17400401","CDM","444","RC","92611","HCPCS",,,"facility","inpatient",,,"GN","1137","1137",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP EVAL MTN FLUOR SWAL","17400401","CDM","444","RC","92611","HCPCS",,,"facility","outpatient",,,"GN","1137","1137",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP ENDOSCOPY SWALLOW (FEES) VID","17400402","CDM","444","RC","92612","HCPCS",,,"facility","inpatient",,,"GN","1134","1134",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP ENDOSCOPY SWALLOW (FEES) VID","17400402","CDM","444","RC","92612","HCPCS",,,"facility","outpatient",,,"GN","1134","1134",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP MCAL EVALUATION SPEECH","17400407","CDM",,,,,,,"facility","inpatient",,,,"409","409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SP MCAL EVALUATION SPEECH","17400407","CDM",,,,,,,"facility","outpatient",,,,"409","409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SP MCAL EVAL LANG","17400408","CDM",,,,,,,"facility","inpatient",,,,"538","538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SP MCAL EVAL LANG","17400408","CDM",,,,,,,"facility","outpatient",,,,"538","538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COGNTIVE FNCTN INTRVEN 1ST 15 MIN","17400411","CDM","440","RC","97129","HCPCS",,,"facility","inpatient",,,"GN","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG COGNTIVE FNCTN INTRVEN 1ST 15 MIN","17400411","CDM","440","RC","97129","HCPCS",,,"facility","outpatient",,,"GN","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","17400412","CDM","440","RC","97130","HCPCS",,,"facility","inpatient",,,"GN","168","168",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","17400412","CDM","440","RC","97130","HCPCS",,,"facility","outpatient",,,"GN","168","168",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG TH SP MCAL THERAPY SPEECH-LANG IND PER HOUR","17400413","CDM",,,,,,,"facility","inpatient",,,,"598","598",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH SP MCAL THERAPY SPEECH-LANG IND PER HOUR","17400413","CDM",,,,,,,"facility","outpatient",,,,"598","598",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH SP MCAL THERAPY SPEECH-LANG IND 1/2 HOUR","17400414","CDM",,,,,,,"facility","inpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH SP MCAL THERAPY SPEECH-LANG IND 1/2 HOUR","17400414","CDM",,,,,,,"facility","outpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH SP TX SP/LANG/COM IND","17400415","CDM","440","RC","92507","HCPCS",,,"facility","inpatient",,,"GN,95","578","578",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP TX SP/LANG/COM IND","17400415","CDM","440","RC","92507","HCPCS",,,"facility","outpatient",,,"GN,95","578","578",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP TX SP/LANG/COM GP","17400416","CDM","440","RC","92508","HCPCS",,,"facility","inpatient",,,"GN,95","170","170",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP TX SP/LANG/COM GP","17400416","CDM","440","RC","92508","HCPCS",,,"facility","outpatient",,,"GN,95","170","170",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH EVALUATION OF SPEECH FLUENCY","17400417","CDM","444","RC","92521","HCPCS",,,"facility","inpatient",,,"GN,95","573","573",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH EVALUATION OF SPEECH FLUENCY","17400417","CDM","444","RC","92521","HCPCS",,,"facility","outpatient",,,"GN,95","573","573",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH EVALUATE SPEECH PRODUCTION","17400418","CDM","444","RC","92522","HCPCS",,,"facility","inpatient",,,"GN,95","607","607",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH EVALUATE SPEECH PRODUCTION","17400418","CDM","444","RC","92522","HCPCS",,,"facility","outpatient",,,"GN,95","607","607",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH EVAL SPEECH SOUND LANG COMPREH","17400419","CDM","444","RC","92523","HCPCS",,,"facility","inpatient",,,"GN,95","803","803",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH EVAL SPEECH SOUND LANG COMPREH","17400419","CDM","444","RC","92523","HCPCS",,,"facility","outpatient",,,"GN,95","803","803",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP BEHAVRAL QUALIT ANALYS VOICE","17400420","CDM","440","RC","92524","HCPCS",,,"facility","inpatient",,,"GN,95","614","614",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP BEHAVRAL QUALIT ANALYS VOICE","17400420","CDM","440","RC","92524","HCPCS",,,"facility","outpatient",,,"GN,95","614","614",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP MCAL EVALUATION SPEECH","17400422","CDM",,,,,,,"facility","inpatient",,,,"412","412",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH SP MCAL EVALUATION SPEECH","17400422","CDM",,,,,,,"facility","outpatient",,,,"412","412",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH SP MCAL EVAL LANG","17400423","CDM",,,,,,,"facility","inpatient",,,,"549","549",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH SP MCAL EVAL LANG","17400423","CDM",,,,,,,"facility","outpatient",,,,"549","549",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH SP TX SWALL/ORAL FNX","17400424","CDM","440","RC","92526","HCPCS",,,"facility","inpatient",,,"GN,95","539","539",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP TX SWALL/ORAL FNX","17400424","CDM","440","RC","92526","HCPCS",,,"facility","outpatient",,,"GN,95","539","539",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP EVAL FNX SWALL","17400425","CDM","444","RC","92610","HCPCS",,,"facility","inpatient",,,"GN,95","826","826",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP EVAL FNX SWALL","17400425","CDM","444","RC","92610","HCPCS",,,"facility","outpatient",,,"GN,95","826","826",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP EVALUATION APHASIA HR","17400426","CDM","440","RC","96105","HCPCS",,,"facility","inpatient",,,"GN,95","668","668",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP EVALUATION APHASIA HR","17400426","CDM","440","RC","96105","HCPCS",,,"facility","outpatient",,,"GN,95","668","668",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP COGNTVE TEST BY HC PRO","17400427","CDM","440","RC","96125","HCPCS",,,"facility","inpatient",,,"GN,95","603","603",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH SP COGNTVE TEST BY HC PRO","17400427","CDM","440","RC","96125","HCPCS",,,"facility","outpatient",,,"GN,95","603","603",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH COGNTIVE FNCTN INTRVEN 1ST 15 MIN","17400428","CDM","440","RC","97129","HCPCS",,,"facility","inpatient",,,"GN,95","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH COGNTIVE FNCTN INTRVEN 1ST 15 MIN","17400428","CDM","440","RC","97129","HCPCS",,,"facility","outpatient",,,"GN,95","239","239",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","17400429","CDM","440","RC","97130","HCPCS",,,"facility","inpatient",,,"GN,95","168","168",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","17400429","CDM","440","RC","97130","HCPCS",,,"facility","outpatient",,,"GN,95","168","168",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG SP CAREGIVER TRAINING 1ST 30 MIN","17400431","CDM","440","RC","97550","HCPCS",,,"facility","inpatient",,,"GN","471","471",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP CAREGIVER TRAINING 1ST 30 MIN","17400431","CDM","440","RC","97550","HCPCS",,,"facility","outpatient",,,"GN","471","471",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP CAREGIVER TRAINING EA ADDL 15 MIN","17400432","CDM","440","RC","97551","HCPCS",,,"facility","inpatient",,,"GN","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP CAREGIVER TRAINING EA ADDL 15 MIN","17400432","CDM","440","RC","97551","HCPCS",,,"facility","outpatient",,,"GN","236","236",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP GROUP CAREGIVER TRAINING","17400433","CDM","440","RC","97552","HCPCS",,,"facility","inpatient",,,"GN","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG SP GROUP CAREGIVER TRAINING","17400433","CDM","440","RC","97552","HCPCS",,,"facility","outpatient",,,"GN","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GN: Services delivered under an outpatient speech language pathology plan of care"
"HCHG AD MCAL AUDIOMETRY COMPLETE AGES 7 TO ADULT","17500005","CDM",,,,,,,"facility","inpatient",,,,"1455","1455",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AD MCAL AUDIOMETRY COMPLETE AGES 7 TO ADULT","17500005","CDM",,,,,,,"facility","outpatient",,,,"1455","1455",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AD AUDIOMETRY COMPLETE","17500020","CDM","471","RC","92557","HCPCS",,,"facility","inpatient",,,,"731","731",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AD AUDIOMETRY COMPLETE","17500020","CDM","471","RC","92557","HCPCS",,,"facility","outpatient",,,,"731","731",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AD VRA EVAL PEDIATRIC GT 3 YEARS","17500027","CDM","471","RC","92579","HCPCS",,,"facility","inpatient",,,,"540","540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AD VRA EVAL PEDIATRIC GT 3 YEARS","17500027","CDM","471","RC","92579","HCPCS",,,"facility","outpatient",,,,"540","540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AD EVALUATION OAE","17500034","CDM","471","RC","92588","HCPCS",,,"facility","inpatient",,,,"484","484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AD EVALUATION OAE","17500034","CDM","471","RC","92588","HCPCS",,,"facility","outpatient",,,,"484","484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALORIC VSTBLR TEST REC BITHERM 4 IRRIGATIONS","17500086","CDM","470","RC","92537","HCPCS",,,"facility","inpatient",,,,"356","356",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALORIC VSTBLR TEST REC BITHERM 4 IRRIGATIONS","17500086","CDM","470","RC","92537","HCPCS",,,"facility","outpatient",,,,"356","356",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALORIC VSTBLR TEST REC BITHERM 3 IRRIGATIONS","17500087","CDM","470","RC","92537","HCPCS",,,"facility","inpatient",,,"52","356","356",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG CALORIC VSTBLR TEST REC BITHERM 3 IRRIGATIONS","17500087","CDM","470","RC","92537","HCPCS",,,"facility","outpatient",,,"52","356","356",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG CALORIC VSTBLR TEST REC MONOTHERM 2 IRRIGATIONS","17500088","CDM","470","RC","92538","HCPCS",,,"facility","inpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALORIC VSTBLR TEST REC MONOTHERM 2 IRRIGATIONS","17500088","CDM","470","RC","92538","HCPCS",,,"facility","outpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALORIC VSTBLR TEST REC MONOTHERM 1 IRRIGATION","17500089","CDM","470","RC","92538","HCPCS",,,"facility","inpatient",,,"52","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG CALORIC VSTBLR TEST REC MONOTHERM 1 IRRIGATION","17500089","CDM","470","RC","92538","HCPCS",,,"facility","outpatient",,,"52","186","186",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG AEP SCREEN W/STIMULI AUTO ALYS INIT IP","17500092","CDM","470","RC","92650","HCPCS",,,"facility","inpatient",,,"GY","633","633",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG AEP SCREEN W/STIMULI AUTO ALYS INIT IP","17500092","CDM","470","RC","92650","HCPCS",,,"facility","outpatient",,,"GY","633","633",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG AEP SCREEN W/STIMULI AUTO ALYS INIT OP","17500093","CDM","470","RC","92650","HCPCS",,,"facility","inpatient",,,"GY","633","633",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG AEP SCREEN W/STIMULI AUTO ALYS INIT OP","17500093","CDM","470","RC","92650","HCPCS",,,"facility","outpatient",,,"GY","633","633",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG AEP SCREEN W/STIMULI AUTO ALYS RESCREEN","17500096","CDM","470","RC","92650","HCPCS",,,"facility","inpatient",,,"GY","633","633",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG AEP SCREEN W/STIMULI AUTO ALYS RESCREEN","17500096","CDM","470","RC","92650","HCPCS",,,"facility","outpatient",,,"GY","633","633",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG AEP THRESHOLD ESTIMATION MLT FREQUENCIES I&R","17500098","CDM","471","RC","92652","HCPCS",,,"facility","inpatient",,,,"1280","1280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEP THRESHOLD ESTIMATION MLT FREQUENCIES I&R","17500098","CDM","471","RC","92652","HCPCS",,,"facility","outpatient",,,,"1280","1280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEP NEURODIAGNOSTIC INTERPRETATION AND REPORT","17500099","CDM","471","RC","92653","HCPCS",,,"facility","inpatient",,,,"1689","1689",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEP NEURODIAGNOSTIC INTERPRETATION AND REPORT","17500099","CDM","471","RC","92653","HCPCS",,,"facility","outpatient",,,,"1689","1689",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABORTED/DISCONTIUNUED CASE OR","20000003","CDM","360","RC",,,,,"facility","inpatient",,,,"2848","2848",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABORTED/DISCONTIUNUED CASE OR","20000003","CDM","360","RC",,,,,"facility","outpatient",,,,"2848","2848",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 ADDL 15 MIN","20000005","CDM","360","RC",,,,,"facility","inpatient",,,,"1625","1625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 ADDL 15 MIN","20000005","CDM","360","RC",,,,,"facility","outpatient",,,,"1625","1625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 FIRST 30 MIN","20000006","CDM","360","RC",,,,,"facility","inpatient",,,,"4925","4925",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 FIRST 30 MIN","20000006","CDM","360","RC",,,,,"facility","outpatient",,,,"4925","4925",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 ADDL 15 MIN","20000007","CDM","360","RC",,,,,"facility","inpatient",,,,"2113","2113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 ADDL 15 MIN","20000007","CDM","360","RC",,,,,"facility","outpatient",,,,"2113","2113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 FIRST 30 MIN","20000008","CDM","360","RC",,,,,"facility","inpatient",,,,"6403","6403",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 FIRST 30 MIN","20000008","CDM","360","RC",,,,,"facility","outpatient",,,,"6403","6403",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 ADDL 15 MIN","20000009","CDM","360","RC",,,,,"facility","inpatient",,,,"2601","2601",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 ADDL 15 MIN","20000009","CDM","360","RC",,,,,"facility","outpatient",,,,"2601","2601",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 FIRST 30 MIN","20000010","CDM","360","RC",,,,,"facility","inpatient",,,,"7880","7880",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 FIRST 30 MIN","20000010","CDM","360","RC",,,,,"facility","outpatient",,,,"7880","7880",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 ADDL 15 MIN","20000011","CDM","360","RC",,,,,"facility","inpatient",,,,"3738","3738",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 ADDL 15 MIN","20000011","CDM","360","RC",,,,,"facility","outpatient",,,,"3738","3738",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 FIRST 30 MIN","20000012","CDM","360","RC",,,,,"facility","inpatient",,,,"11328","11328",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 FIRST 30 MIN","20000012","CDM","360","RC",,,,,"facility","outpatient",,,,"11328","11328",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 ADDL 15 MIN","20000013","CDM","360","RC",,,,,"facility","inpatient",,,,"4388","4388",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 ADDL 15 MIN","20000013","CDM","360","RC",,,,,"facility","outpatient",,,,"4388","4388",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 FIRST 30 MIN","20000014","CDM","360","RC",,,,,"facility","inpatient",,,,"13298","13298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 FIRST 30 MIN","20000014","CDM","360","RC",,,,,"facility","outpatient",,,,"13298","13298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 ADDL 15 MIN","20000015","CDM","360","RC",,,,,"facility","inpatient",,,,"5689","5689",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 ADDL 15 MIN","20000015","CDM","360","RC",,,,,"facility","outpatient",,,,"5689","5689",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 FIRST 30 MIN","20000016","CDM","360","RC",,,,,"facility","inpatient",,,,"17238","17238",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 FIRST 30 MIN","20000016","CDM","360","RC",,,,,"facility","outpatient",,,,"17238","17238",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ SINUS TRACT TX","20000044","CDM","361","RC","20500","HCPCS",,,"facility","inpatient",,,,"1041","1041",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ SINUS TRACT TX","20000044","CDM","361","RC","20500","HCPCS",,,"facility","outpatient",,,,"1041","1041",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX SALIVARY GLAND NDL","20000048","CDM","361","RC","42400","HCPCS",,,"facility","inpatient",,,,"3022","3022",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX SALIVARY GLAND NDL","20000048","CDM","361","RC","42400","HCPCS",,,"facility","outpatient",,,,"3022","3022",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ERCP W/SPHINC/PAPIL","20000050","CDM","361","RC","43262","HCPCS",,,"facility","inpatient",,,,"8388","8388",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ERCP W/SPHINC/PAPIL","20000050","CDM","361","RC","43262","HCPCS",,,"facility","outpatient",,,,"8388","8388",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ERCP RMVL CALC DEBRIS FROM DUCT","20000051","CDM","361","RC","43264","HCPCS",,,"facility","inpatient",,,,"7080","7080",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ERCP RMVL CALC DEBRIS FROM DUCT","20000051","CDM","361","RC","43264","HCPCS",,,"facility","outpatient",,,,"7080","7080",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV BLK SUBARACH","20000069","CDM","361","RC","62280","HCPCS",,,"facility","inpatient",,,,"2570","2570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV BLK SUBARACH","20000069","CDM","361","RC","62280","HCPCS",,,"facility","outpatient",,,,"2570","2570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ERCP WITH BIOPSY","20000071","CDM","361","RC","43261","HCPCS",,,"facility","inpatient",,,,"6833","6833",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ERCP WITH BIOPSY","20000071","CDM","361","RC","43261","HCPCS",,,"facility","outpatient",,,,"6833","6833",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VILLUS SAMPLING","20000076","CDM","361","RC","59015","HCPCS",,,"facility","inpatient",,,,"1439","1439",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VILLUS SAMPLING","20000076","CDM","361","RC","59015","HCPCS",,,"facility","outpatient",,,,"1439","1439",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 1ST 30M NONOR","20000081","CDM","360","RC",,,,,"facility","inpatient",,,,"4433","4433",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 1ST 30M NONOR","20000081","CDM","360","RC",,,,,"facility","outpatient",,,,"4433","4433",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 ADD 15M NONOR","20000082","CDM","360","RC",,,,,"facility","inpatient",,,,"1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 ADD 15M NONOR","20000082","CDM","360","RC",,,,,"facility","outpatient",,,,"1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 1ST 30M NONOR","20000083","CDM","360","RC",,,,,"facility","inpatient",,,,"5763","5763",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 1ST 30M NONOR","20000083","CDM","360","RC",,,,,"facility","outpatient",,,,"5763","5763",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 ADD 15M NONOR","20000084","CDM","360","RC",,,,,"facility","inpatient",,,,"1902","1902",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 ADD 15M NONOR","20000084","CDM","360","RC",,,,,"facility","outpatient",,,,"1902","1902",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 1ST 30M NONOR","20000085","CDM","360","RC",,,,,"facility","inpatient",,,,"7092","7092",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 1ST 30M NONOR","20000085","CDM","360","RC",,,,,"facility","outpatient",,,,"7092","7092",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 ADD 15M NONOR","20000086","CDM","360","RC",,,,,"facility","inpatient",,,,"2340","2340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 ADD 15M NONOR","20000086","CDM","360","RC",,,,,"facility","outpatient",,,,"2340","2340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 1ST 30M NONOR","20000087","CDM","360","RC",,,,,"facility","inpatient",,,,"10195","10195",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 1ST 30M NONOR","20000087","CDM","360","RC",,,,,"facility","outpatient",,,,"10195","10195",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 ADD 15M NONOR","20000088","CDM","360","RC",,,,,"facility","inpatient",,,,"3364","3364",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 ADD 15M NONOR","20000088","CDM","360","RC",,,,,"facility","outpatient",,,,"3364","3364",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 1ST 30M NONOR","20000089","CDM","360","RC",,,,,"facility","inpatient",,,,"11968","11968",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 1ST 30M NONOR","20000089","CDM","360","RC",,,,,"facility","outpatient",,,,"11968","11968",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 ADD 15M NONOR","20000090","CDM","360","RC",,,,,"facility","inpatient",,,,"3950","3950",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 ADD 15M NONOR","20000090","CDM","360","RC",,,,,"facility","outpatient",,,,"3950","3950",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 MCAL 1ST HR","20000111","CDM",,,,,,,"facility","inpatient",,,,"8175","8175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 MCAL 1ST HR","20000111","CDM",,,,,,,"facility","outpatient",,,,"8175","8175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 MCAL1ST SUBSEQ HALF","20000112","CDM",,,,,,,"facility","inpatient",,,,"3250","3250",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 MCAL1ST SUBSEQ HALF","20000112","CDM",,,,,,,"facility","outpatient",,,,"3250","3250",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 MCAL 2ND+ EA SUBSEQ 1/2HR","20000113","CDM",,,,,,,"facility","inpatient",,,,"3250","3250",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 MCAL 2ND+ EA SUBSEQ 1/2HR","20000113","CDM",,,,,,,"facility","outpatient",,,,"3250","3250",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 MCAL 1ST HR","20000211","CDM",,,,,,,"facility","inpatient",,,,"10629","10629",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 MCAL 1ST HR","20000211","CDM",,,,,,,"facility","outpatient",,,,"10629","10629",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 MCAL 1ST SUBSEQ 1/2HR","20000212","CDM",,,,,,,"facility","inpatient",,,,"4226","4226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 MCAL 1ST SUBSEQ 1/2HR","20000212","CDM",,,,,,,"facility","outpatient",,,,"4226","4226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 MCAL 2ND+ EA SUBSEQ 1/2HR","20000213","CDM",,,,,,,"facility","inpatient",,,,"4226","4226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 MCAL 2ND+ EA SUBSEQ 1/2HR","20000213","CDM",,,,,,,"facility","outpatient",,,,"4226","4226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 MCAL 1ST HR","20000311","CDM",,,,,,,"facility","inpatient",,,,"13082","13082",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 MCAL 1ST HR","20000311","CDM",,,,,,,"facility","outpatient",,,,"13082","13082",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 MCAL 1ST SUBSEQ 1/2HR","20000312","CDM",,,,,,,"facility","inpatient",,,,"5202","5202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 MCAL 1ST SUBSEQ 1/2HR","20000312","CDM",,,,,,,"facility","outpatient",,,,"5202","5202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 MCAL 2ND+ EA SUBSEQ 1/2HR","20000313","CDM",,,,,,,"facility","inpatient",,,,"5202","5202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 MCAL 2ND+ EA SUBSEQ 1/2HR","20000313","CDM",,,,,,,"facility","outpatient",,,,"5202","5202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 MCAL 1ST HR","20000411","CDM",,,,,,,"facility","inpatient",,,,"18804","18804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 MCAL 1ST HR","20000411","CDM",,,,,,,"facility","outpatient",,,,"18804","18804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 MCAL 1ST SUBSEQ 1/2HR","20000412","CDM",,,,,,,"facility","inpatient",,,,"7476","7476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 MCAL 1ST SUBSEQ 1/2HR","20000412","CDM",,,,,,,"facility","outpatient",,,,"7476","7476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 MCAL 2ND+ EA SUBSEQ 1/2HR","20000413","CDM",,,,,,,"facility","inpatient",,,,"7476","7476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 MCAL 2ND+ EA SUBSEQ 1/2HR","20000413","CDM",,,,,,,"facility","outpatient",,,,"7476","7476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 MCAL 1ST HR","20000511","CDM",,,,,,,"facility","inpatient",,,,"22074","22074",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 MCAL 1ST HR","20000511","CDM",,,,,,,"facility","outpatient",,,,"22074","22074",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 MCAL 1ST SUBSEQ 1/2HR","20000512","CDM",,,,,,,"facility","inpatient",,,,"8776","8776",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 MCAL 1ST SUBSEQ 1/2HR","20000512","CDM",,,,,,,"facility","outpatient",,,,"8776","8776",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 MCAL 2ND+ EA SUBSEQ 1/2HR","20000513","CDM",,,,,,,"facility","inpatient",,,,"8776","8776",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 5 MCAL 2ND+ EA SUBSEQ 1/2HR","20000513","CDM",,,,,,,"facility","outpatient",,,,"8776","8776",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 MCAL 1ST HR","20000611","CDM",,,,,,,"facility","inpatient",,,,"28616","28616",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 MCAL 1ST HR","20000611","CDM",,,,,,,"facility","outpatient",,,,"28616","28616",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 MCAL 1ST SUBSEQ 1/2HR","20000612","CDM",,,,,,,"facility","inpatient",,,,"11378","11378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 MCAL 1ST SUBSEQ 1/2HR","20000612","CDM",,,,,,,"facility","outpatient",,,,"11378","11378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 MCAL 2ND+ EA SUBSEQ 1/2HR","20000613","CDM",,,,,,,"facility","inpatient",,,,"11378","11378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 6 MCAL 2ND+ EA SUBSEQ 1/2HR","20000613","CDM",,,,,,,"facility","outpatient",,,,"11378","11378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTERDISCAL PERQ ASPIR DX","20000641","CDM","361","RC","62267","HCPCS",,,"facility","inpatient",,,,"3325","3325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTERDISCAL PERQ ASPIR DX","20000641","CDM","361","RC","62267","HCPCS",,,"facility","outpatient",,,,"3325","3325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABORTED/DISCONTINUED CASE ENDO","20000660","CDM","750","RC",,,,,"facility","inpatient",,,,"1375","1375",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABORTED/DISCONTINUED CASE ENDO","20000660","CDM","750","RC",,,,,"facility","outpatient",,,,"1375","1375",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KIDNEY ACQUISITION CADAVER","20000662","CDM","812","RC",,,,,"facility","inpatient",,,,"218000","218000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KIDNEY ACQUISITION CADAVER","20000662","CDM","812","RC",,,,,"facility","outpatient",,,,"218000","218000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KIDNEY ACQUISITION LIVE DONOR","20000663","CDM","811","RC",,,,,"facility","inpatient",,,,"113000","113000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KIDNEY ACQUISITION LIVE DONOR","20000663","CDM","811","RC",,,,,"facility","outpatient",,,,"113000","113000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEART ACQUISITION","20000664","CDM","812","RC",,,,,"facility","inpatient",,,,"188000","188000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEART ACQUISITION","20000664","CDM","812","RC",,,,,"facility","outpatient",,,,"188000","188000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PANCREAS ACQUISITION CADAVER","20000665","CDM","812","RC",,,,,"facility","inpatient",,,,"183000","183000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PANCREAS ACQUISITION CADAVER","20000665","CDM","812","RC",,,,,"facility","outpatient",,,,"183000","183000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIVER ACQUISITION CADAVER","20000666","CDM","812","RC",,,,,"facility","inpatient",,,,"199000","199000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIVER ACQUISITION CADAVER","20000666","CDM","812","RC",,,,,"facility","outpatient",,,,"199000","199000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIVER ACQUISITION LIVE DONOR","20000667","CDM","811","RC",,,,,"facility","inpatient",,,,"199000","199000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIVER ACQUISITION LIVE DONOR","20000667","CDM","811","RC",,,,,"facility","outpatient",,,,"199000","199000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY RESPIRATORY DIAGNOSTIC","20000673","CDM","361","RC",,,,,"facility","inpatient",,,,"1692","1692",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY RESPIRATORY DIAGNOSTIC","20000673","CDM","361","RC",,,,,"facility","outpatient",,,,"1692","1692",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY RESPIRATORY PLUS 1 INTERVENTION","20000674","CDM","361","RC",,,,,"facility","inpatient",,,,"3262","3262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY RESPIRATORY PLUS 1 INTERVENTION","20000674","CDM","361","RC",,,,,"facility","outpatient",,,,"3262","3262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY RESPIRATORY DX PLUS 2 INTERVENTIONS","20000675","CDM","361","RC",,,,,"facility","inpatient",,,,"4811","4811",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY RESPIRATORY DX PLUS 2 INTERVENTIONS","20000675","CDM","361","RC",,,,,"facility","outpatient",,,,"4811","4811",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY RESPIRATORY DX PLUS 3/MORE INTERVENTIONS","20000676","CDM","361","RC",,,,,"facility","inpatient",,,,"6701","6701",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY RESPIRATORY DX PLUS 3/MORE INTERVENTIONS","20000676","CDM","361","RC",,,,,"facility","outpatient",,,,"6701","6701",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANAL INF PMP W/RPR &RFILL","20000678","CDM","361","RC","62369","HCPCS",,,"facility","inpatient",,,,"1959","1959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANAL INF PMP W/RPR &RFILL","20000678","CDM","361","RC","62369","HCPCS",,,"facility","outpatient",,,,"1959","1959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SLIT LAMP PROCEDURE","20000681","CDM","920","RC","92285","HCPCS",,,"facility","inpatient",,,,"622","622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SLIT LAMP PROCEDURE","20000681","CDM","920","RC","92285","HCPCS",,,"facility","outpatient",,,,"622","622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROPH RET DETCH PHOTOCOAG","20000699","CDM","361","RC","67145","HCPCS",,,"facility","inpatient",,,,"5293","5293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROPH RET DETCH PHOTOCOAG","20000699","CDM","361","RC","67145","HCPCS",,,"facility","outpatient",,,,"5293","5293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARACENTSIS ABD NO IM","20000708","CDM","361","RC","49082","HCPCS",,,"facility","inpatient",,,,"3084","3084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARACENTSIS ABD NO IM","20000708","CDM","361","RC","49082","HCPCS",,,"facility","outpatient",,,,"3084","3084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PV FACET W IMAGE GUIDANCE C/T 1 LVL BIL","20000710","CDM","361","RC","64490","HCPCS",,,"facility","inpatient",,,"50","7342","7342",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ PV FACET W IMAGE GUIDANCE C/T 1 LVL BIL","20000710","CDM","361","RC","64490","HCPCS",,,"facility","outpatient",,,"50","7342","7342",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ AA/STRD AGENT AXILLARY NERVE IMG BIL","20000711","CDM","361","RC","64417","HCPCS",,,"facility","inpatient",,,"50","6933","6933",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ AA/STRD AGENT AXILLARY NERVE IMG BIL","20000711","CDM","361","RC","64417","HCPCS",,,"facility","outpatient",,,"50","6933","6933",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ AA/STRDBRACHIAL PLEX IMG BIL","20000712","CDM","361","RC","64415","HCPCS",,,"facility","inpatient",,,"50","10353","10353",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ AA/STRDBRACHIAL PLEX IMG BIL","20000712","CDM","361","RC","64415","HCPCS",,,"facility","outpatient",,,"50","10353","10353",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG HISTOTRIPSY MAL HEPATOCELLULAR TISS W/IMG GDN","20100001","CDM","361","RC","0686T","HCPCS",,,"facility","inpatient",,,,"108150","108150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HISTOTRIPSY MAL HEPATOCELLULAR TISS W/IMG GDN","20100001","CDM","361","RC","0686T","HCPCS",,,"facility","outpatient",,,,"108150","108150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTOURETHROSCOPY","20200007","CDM","750","RC",,,,,"facility","inpatient",,,,"5723","5723",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTOURETHROSCOPY","20200007","CDM","750","RC",,,,,"facility","outpatient",,,,"5723","5723",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE G/C TUBE PERC","20200034","CDM","361","RC","49450","HCPCS",,,"facility","inpatient",,,,"3430","3430",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE G/C TUBE PERC","20200034","CDM","361","RC","49450","HCPCS",,,"facility","outpatient",,,,"3430","3430",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY GI DIAGNOSTIC","20200035","CDM","750","RC",,,,,"facility","inpatient",,,,"2432","2432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY GI DIAGNOSTIC","20200035","CDM","750","RC",,,,,"facility","outpatient",,,,"2432","2432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY GI DIAGNOSTIC PLUS 1 INTERVENTION","20200036","CDM","750","RC",,,,,"facility","inpatient",,,,"3678","3678",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY GI DIAGNOSTIC PLUS 1 INTERVENTION","20200036","CDM","750","RC",,,,,"facility","outpatient",,,,"3678","3678",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY GI DIAGNOSTIC PLUS 2 INTERVENTIONS","20200037","CDM","750","RC",,,,,"facility","inpatient",,,,"5731","5731",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY GI DIAGNOSTIC PLUS 2 INTERVENTIONS","20200037","CDM","750","RC",,,,,"facility","outpatient",,,,"5731","5731",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY GI DIAGNOSTIC PLUS 3/MORE INTERVENTIONS","20200038","CDM","750","RC",,,,,"facility","inpatient",,,,"7785","7785",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOSCOPY GI DIAGNOSTIC PLUS 3/MORE INTERVENTIONS","20200038","CDM","750","RC",,,,,"facility","outpatient",,,,"7785","7785",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANORECTAL MANOMETRY","20200043","CDM","750","RC","91122","HCPCS",,,"facility","inpatient",,,,"3133","3133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANORECTAL MANOMETRY","20200043","CDM","750","RC","91122","HCPCS",,,"facility","outpatient",,,,"3133","3133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLON MTLTY STDY 6HR/MORE","20200044","CDM","750","RC","91117","HCPCS",,,"facility","inpatient",,,,"4877","4877",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLON MTLTY STDY 6HR/MORE","20200044","CDM","750","RC","91117","HCPCS",,,"facility","outpatient",,,,"4877","4877",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLON MTLTY STDY LT 6 HRS","20200045","CDM","750","RC","91117","HCPCS",,,"facility","inpatient",,,"52","4877","4877",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG COLON MTLTY STDY LT 6 HRS","20200045","CDM","750","RC","91117","HCPCS",,,"facility","outpatient",,,"52","4877","4877",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG REMOV FECAL IMP OR FB W/A","20200046","CDM","361","RC","45915","HCPCS",,,"facility","inpatient",,,,"10214","10214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOV FECAL IMP OR FB W/A","20200046","CDM","361","RC","45915","HCPCS",,,"facility","outpatient",,,,"10214","10214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPH IMPED FUNCTION","20200048","CDM","750","RC","91037","HCPCS",,,"facility","inpatient",,,,"2467","2467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPH IMPED FUNCTION","20200048","CDM","750","RC","91037","HCPCS",,,"facility","outpatient",,,,"2467","2467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPH IMPED FUNCT >1HR","20200049","CDM","750","RC","91038","HCPCS",,,"facility","inpatient",,,,"3649","3649",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPH IMPED FUNCT >1HR","20200049","CDM","750","RC","91038","HCPCS",,,"facility","outpatient",,,,"3649","3649",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GI WIRELESS CAPSULE MEASURE","20200050","CDM","750","RC","91112","HCPCS",,,"facility","inpatient",,,,"3298","3298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GI WIRELESS CAPSULE MEASURE","20200050","CDM","750","RC","91112","HCPCS",,,"facility","outpatient",,,,"3298","3298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIVER ELASTOGRAPHY","20200051","CDM","750","RC","91200","HCPCS",,,"facility","inpatient",,,,"772","772",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIVER ELASTOGRAPHY","20200051","CDM","750","RC","91200","HCPCS",,,"facility","outpatient",,,,"772","772",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RECTAL SENSATION TEST","20200052","CDM","750","RC","91120","HCPCS",,,"facility","inpatient",,,,"6538","6538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RECTAL SENSATION TEST","20200052","CDM","750","RC","91120","HCPCS",,,"facility","outpatient",,,,"6538","6538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BFB TRAINING 1ST 15 MIN","20200054","CDM","750","RC","90912","HCPCS",,,"facility","inpatient",,,,"1040","1040",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BFB TRAINING 1ST 15 MIN","20200054","CDM","750","RC","90912","HCPCS",,,"facility","outpatient",,,,"1040","1040",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BFB TRAINING EA ADDL 15 MIN","20200055","CDM","750","RC","90913","HCPCS",,,"facility","inpatient",,,,"570","570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BFB TRAINING EA ADDL 15 MIN","20200055","CDM","750","RC","90913","HCPCS",,,"facility","outpatient",,,,"570","570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RECTAL SENSATION TONE&COMPLIANCE STUDY","20200059","CDM","750","RC","91124","HCPCS",,,"facility","inpatient",,,,"6538","6538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RECTAL SENSATION TONE&COMPLIANCE STUDY","20200059","CDM","750","RC","91124","HCPCS",,,"facility","outpatient",,,,"6538","6538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANRCT MANO RCT SENSATION&RCT BALO EXPULSION TST","20200060","CDM","750","RC","91125","HCPCS",,,"facility","inpatient",,,,"3133","3133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANRCT MANO RCT SENSATION&RCT BALO EXPULSION TST","20200060","CDM","750","RC","91125","HCPCS",,,"facility","outpatient",,,,"3133","3133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PV FACET C/T 1 LVL","20300002","CDM","361","RC","64490","HCPCS",,,"facility","inpatient",,,,"4895","4895",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PV FACET C/T 1 LVL","20300002","CDM","361","RC","64490","HCPCS",,,"facility","outpatient",,,,"4895","4895",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PV FACET C/T 3 LVL","20300005","CDM","361","RC","64492","HCPCS",,,"facility","inpatient",,,,"1742","1742",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PV FACET C/T 3 LVL","20300005","CDM","361","RC","64492","HCPCS",,,"facility","outpatient",,,,"1742","1742",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION FACET L/S 1 LVL","20300006","CDM","361","RC","64493","HCPCS",,,"facility","inpatient",,,,"5005","5005",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION FACET L/S 1 LVL","20300006","CDM","361","RC","64493","HCPCS",,,"facility","outpatient",,,,"5005","5005",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION FACET L/S 3 LVL","20300007","CDM","361","RC","64495","HCPCS",,,"facility","inpatient",,,,"1930","1930",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION FACET L/S 3 LVL","20300007","CDM","361","RC","64495","HCPCS",,,"facility","outpatient",,,,"1930","1930",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXC SFT LSN FACE SBQ>=2CM","20300093","CDM","361","RC","21012","HCPCS",,,"facility","inpatient",,,,"12200","12200",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXC SFT LSN FACE SBQ>=2CM","20300093","CDM","361","RC","21012","HCPCS",,,"facility","outpatient",,,,"12200","12200",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LITHOTRIPSY ESWL","20400001","CDM","790","RC",,,,,"facility","inpatient",,,,"25008","25008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LITHOTRIPSY ESWL","20400001","CDM","790","RC",,,,,"facility","outpatient",,,,"25008","25008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LITHOTRIPSY LASER","20400005","CDM","360","RC",,,,,"facility","inpatient",,,,"44909","44909",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LITHOTRIPSY LASER","20400005","CDM","360","RC",,,,,"facility","outpatient",,,,"44909","44909",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANES EPIDURAL CRNA MANAGED","20500008","CDM","370","RC",,,,,"facility","inpatient",,,,"2107","2107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANES EPIDURAL CRNA MANAGED","20500008","CDM","370","RC",,,,,"facility","outpatient",,,,"2107","2107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REGIONAL BLOCK FINGERS","20500009","CDM","370","RC",,,,,"facility","inpatient",,,,"290","290",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REGIONAL BLOCK FINGERS","20500009","CDM","370","RC",,,,,"facility","outpatient",,,,"290","290",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REGIONAL BLOCK TOES","20500010","CDM","370","RC",,,,,"facility","inpatient",,,,"232","232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REGIONAL BLOCK TOES","20500010","CDM","370","RC",,,,,"facility","outpatient",,,,"232","232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STANDARD GENERAL ANESTHESIA 3 HOURS OR LESS","20500021","CDM","370","RC",,,,,"facility","inpatient",,,,"2907","2907",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STANDARD GENERAL ANESTHESIA 3 HOURS OR LESS","20500021","CDM","370","RC",,,,,"facility","outpatient",,,,"2907","2907",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STANDARD GENERAL ANESTHESIA MORE THAN 3 HOURS","20500022","CDM","370","RC",,,,,"facility","inpatient",,,,"8484","8484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STANDARD GENERAL ANESTHESIA MORE THAN 3 HOURS","20500022","CDM","370","RC",,,,,"facility","outpatient",,,,"8484","8484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPLEX GENERAL ANESTHESIA 3 HOURS OR LESS","20500023","CDM","370","RC",,,,,"facility","inpatient",,,,"5003","5003",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPLEX GENERAL ANESTHESIA 3 HOURS OR LESS","20500023","CDM","370","RC",,,,,"facility","outpatient",,,,"5003","5003",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPLEX GENERAL ANESTHESIA MORE THAN 3 HOURS","20500024","CDM","370","RC",,,,,"facility","inpatient",,,,"11050","11050",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPLEX GENERAL ANESTHESIA MORE THAN 3 HOURS","20500024","CDM","370","RC",,,,,"facility","outpatient",,,,"11050","11050",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MONITORED ANESTHESIA CARE/REGIONAL ANESTHESIA","20500025","CDM","370","RC",,,,,"facility","inpatient",,,,"2236","2236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MONITORED ANESTHESIA CARE/REGIONAL ANESTHESIA","20500025","CDM","370","RC",,,,,"facility","outpatient",,,,"2236","2236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED SAME MD/QHP LT 5 YRS","20500032","CDM","370","RC","99151","HCPCS",,,"facility","inpatient",,,,"2107","2107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED SAME MD/QHP LT 5 YRS","20500032","CDM","370","RC","99151","HCPCS",,,"facility","outpatient",,,,"2107","2107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED SAME MD/QHP GT 5 YRS","20500033","CDM","370","RC","99152","HCPCS",,,"facility","inpatient",,,,"431","431",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED SAME MD/QHP GT 5 YRS","20500033","CDM","370","RC","99152","HCPCS",,,"facility","outpatient",,,,"431","431",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED OTH MD/QHP LT 5 YRS","20500035","CDM","370","RC","99155","HCPCS",,,"facility","inpatient",,,,"440","440",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED OTH MD/QHP LT 5 YRS","20500035","CDM","370","RC","99155","HCPCS",,,"facility","outpatient",,,,"440","440",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED OTH MD/QHP GT 5 YRS","20500036","CDM","370","RC","99156","HCPCS",,,"facility","inpatient",,,,"549","549",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED OTH MD/QHP GT 5 YRS","20500036","CDM","370","RC","99156","HCPCS",,,"facility","outpatient",,,,"549","549",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED ENDO SAME MD/QHP GT 5YRS","20500038","CDM","370","RC","G0500","HCPCS",,,"facility","inpatient",,,,"431","431",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOD SED ENDO SAME MD/QHP GT 5YRS","20500038","CDM","370","RC","G0500","HCPCS",,,"facility","outpatient",,,,"431","431",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU COMPLEX ADDITIONAL 15 MINUTES","20600000","CDM","710","RC",,,,,"facility","inpatient",,,,"952","952",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU COMPLEX ADDITIONAL 15 MINUTES","20600000","CDM","710","RC",,,,,"facility","outpatient",,,,"952","952",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU COMPLEX FIRST 30 MINUTES","20600001","CDM","710","RC",,,,,"facility","inpatient",,,,"2412","2412",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU COMPLEX FIRST 30 MINUTES","20600001","CDM","710","RC",,,,,"facility","outpatient",,,,"2412","2412",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU STANDARD LEVEL 1 ADDITIONAL 15 MINUTES","20600002","CDM","710","RC",,,,,"facility","inpatient",,,,"410","410",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU STANDARD LEVEL 1 ADDITIONAL 15 MINUTES","20600002","CDM","710","RC",,,,,"facility","outpatient",,,,"410","410",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU STANDARD LEVEL 1 FIRST 30 MINUTES","20600003","CDM","710","RC",,,,,"facility","inpatient",,,,"1084","1084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU STANDARD LEVEL 1 FIRST 30 MINUTES","20600003","CDM","710","RC",,,,,"facility","outpatient",,,,"1084","1084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU STANDARD LEVEL 2 ADDL 15 MINUTES","20600004","CDM","710","RC",,,,,"facility","inpatient",,,,"654","654",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU STANDARD LEVEL 2 ADDL 15 MINUTES","20600004","CDM","710","RC",,,,,"facility","outpatient",,,,"654","654",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU STANDARD LEVEL 2 FIRST 30 MINUTES","20600005","CDM","710","RC",,,,,"facility","inpatient",,,,"1570","1570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACU STANDARD LEVEL 2 FIRST 30 MINUTES","20600005","CDM","710","RC",,,,,"facility","outpatient",,,,"1570","1570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLL BLD IMP VEN ACCS DEV","20600008","CDM","361","RC","36591","HCPCS",,,"facility","inpatient",,,,"447","447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLL BLD IMP VEN ACCS DEV","20600008","CDM","361","RC","36591","HCPCS",,,"facility","outpatient",,,,"447","447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOVERSION ELECTRIC EXTERNAL","20600013","CDM","940","RC","92960","HCPCS",,,"facility","inpatient",,,,"4162","4162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOVERSION ELECTRIC EXTERNAL","20600013","CDM","940","RC","92960","HCPCS",,,"facility","outpatient",,,,"4162","4162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT TRNCTH PLCMNT EXT VER ART OPN/PRQ INT VSL","21000000","CDM","361","RC","0075T","HCPCS",,,"facility","inpatient",,,,"27819","27819",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT TRNCTH PLCMNT EXT VER ART OPN/PRQ INT VSL","21000000","CDM","361","RC","0075T","HCPCS",,,"facility","outpatient",,,,"27819","27819",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT TRNSCTH PLCMNT EXT VERT ART EA ADD VSL","21000001","CDM","361","RC","0076T","HCPCS",,,"facility","inpatient",,,,"10842","10842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT TRNSCTH PLCMNT EXT VERT ART EA ADD VSL","21000001","CDM","361","RC","0076T","HCPCS",,,"facility","outpatient",,,,"10842","10842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAINAGE ABSCESS SIMPLE/SINGLE","21000004","CDM","361","RC","10060","HCPCS",,,"facility","inpatient",,,,"1268","1268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAINAGE ABSCESS SIMPLE/SINGLE","21000004","CDM","361","RC","10060","HCPCS",,,"facility","outpatient",,,,"1241","1241",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMATOMA EVACUATION","21000007","CDM","361","RC","10140","HCPCS",,,"facility","inpatient",,,,"5980","5980",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMATOMA EVACUATION","21000007","CDM","361","RC","10140","HCPCS",,,"facility","outpatient",,,,"5980","5980",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION OF ABSCESS, HEMATOMA, CYST","21000008","CDM","361","RC","10160","HCPCS",,,"facility","inpatient",,,,"1494","1494",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION OF ABSCESS, HEMATOMA, CYST","21000008","CDM","361","RC","10160","HCPCS",,,"facility","outpatient",,,,"1494","1494",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SIMPLE REPAIR WOUND 2.5CM OR LESS","21000024","CDM","361","RC","12001","HCPCS",,,"facility","inpatient",,,,"1194","1194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SIMPLE REPAIR WOUND 2.5CM OR LESS","21000024","CDM","361","RC","12001","HCPCS",,,"facility","outpatient",,,,"1194","1194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMICAL CAUTERIZATION OR GRANULATION OF TISSUE","21000038","CDM","361","RC","17250","HCPCS",,,"facility","inpatient",,,,"679","679",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMICAL CAUTERIZATION OR GRANULATION OF TISSUE","21000038","CDM","361","RC","17250","HCPCS",,,"facility","outpatient",,,,"679","679",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION BREAST CYST","21000039","CDM","361","RC","19000","HCPCS",,,"facility","inpatient",,,,"1878","1878",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION BREAST CYST","21000039","CDM","361","RC","19000","HCPCS",,,"facility","outpatient",,,,"1878","1878",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION BREAST CYST EACH ADDITIONAL CYST","21000040","CDM","361","RC","19001","HCPCS",,,"facility","inpatient",,,,"985","985",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION BREAST CYST EACH ADDITIONAL CYST","21000040","CDM","361","RC","19001","HCPCS",,,"facility","outpatient",,,,"985","985",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION FOR DUCTOGRAM OR GALACTOGRAM","21000041","CDM","361","RC","19030","HCPCS",,,"facility","inpatient",,,,"1218","1218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION FOR DUCTOGRAM OR GALACTOGRAM","21000041","CDM","361","RC","19030","HCPCS",,,"facility","outpatient",,,,"1218","1218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY BREAST PERCUTANEOUS W/O IMAGING","21000042","CDM","361","RC","19100","HCPCS",,,"facility","inpatient",,,,"4004","4004",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY BREAST PERCUTANEOUS W/O IMAGING","21000042","CDM","361","RC","19100","HCPCS",,,"facility","outpatient",,,,"4004","4004",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY MUSCLE","21000049","CDM","361","RC","20206","HCPCS",,,"facility","inpatient",,,,"3998","3998",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY MUSCLE","21000049","CDM","361","RC","20206","HCPCS",,,"facility","outpatient",,,,"3998","3998",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY BONE SUPERFICIAL","21000050","CDM","361","RC","20220","HCPCS",,,"facility","inpatient",,,,"4320","4320",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY BONE SUPERFICIAL","21000050","CDM","361","RC","20220","HCPCS",,,"facility","outpatient",,,,"4320","4320",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY BONE DEEP","21000051","CDM","361","RC","20225","HCPCS",,,"facility","inpatient",,,,"6326","6326",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY BONE DEEP","21000051","CDM","361","RC","20225","HCPCS",,,"facility","outpatient",,,,"6326","6326",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SINOGRAM","21000052","CDM","361","RC","20501","HCPCS",,,"facility","inpatient",,,,"958","958",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SINOGRAM","21000052","CDM","361","RC","20501","HCPCS",,,"facility","outpatient",,,,"958","958",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION TENDON SHEATH OR LIGAMENT SINGLE","21000053","CDM","361","RC","20550","HCPCS",,,"facility","inpatient",,,,"1727","1727",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION TENDON SHEATH OR LIGAMENT SINGLE","21000053","CDM","361","RC","20550","HCPCS",,,"facility","outpatient",,,,"1600","1600",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION TRIGGER POINT 1 TO 2 MUSCLES","21000054","CDM","361","RC","20552","HCPCS",,,"facility","inpatient",,,,"1556","1556",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION TRIGGER POINT 1 TO 2 MUSCLES","21000054","CDM","361","RC","20552","HCPCS",,,"facility","outpatient",,,,"1556","1556",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION TRIGGER POINT GREATER THAN 2  MUSCLES","21000055","CDM","361","RC","20553","HCPCS",,,"facility","inpatient",,,,"1541","1541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION TRIGGER POINT GREATER THAN 2  MUSCLES","21000055","CDM","361","RC","20553","HCPCS",,,"facility","outpatient",,,,"1541","1541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ SMALL JOINT/BURSA W/O US","21000056","CDM","361","RC","20600","HCPCS",,,"facility","inpatient",,,,"1850","1850",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ SMALL JOINT/BURSA W/O US","21000056","CDM","361","RC","20600","HCPCS",,,"facility","outpatient",,,,"1751","1751",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ INTERMEDIATE JOINT/BURSA W/O US","21000057","CDM","361","RC","20605","HCPCS",,,"facility","inpatient",,,,"1808","1808",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ INTERMEDIATE JOINT/BURSA W/O US","21000057","CDM","361","RC","20605","HCPCS",,,"facility","outpatient",,,,"1808","1808",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION OR ASPIRATION GANGLION CYST","21000059","CDM","361","RC","20612","HCPCS",,,"facility","inpatient",,,,"986","986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION OR ASPIRATION GANGLION CYST","21000059","CDM","361","RC","20612","HCPCS",,,"facility","outpatient",,,,"986","986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLATION BONE TUMORS RF PERCUTANEOUS","21000060","CDM","361","RC","20982","HCPCS",,,"facility","inpatient",,,,"20362","20362",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLATION BONE TUMORS RF PERCUTANEOUS","21000060","CDM","361","RC","20982","HCPCS",,,"facility","outpatient",,,,"20362","20362",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM TMJ","21000061","CDM","361","RC","21116","HCPCS",,,"facility","inpatient",,,,"2194","2194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM TMJ","21000061","CDM","361","RC","21116","HCPCS",,,"facility","outpatient",,,,"2194","2194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE NECK","21000062","CDM","361","RC","21550","HCPCS",,,"facility","inpatient",,,,"5867","5867",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE NECK","21000062","CDM","361","RC","21550","HCPCS",,,"facility","outpatient",,,,"5867","5867",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INCISION AND DRAINAGE HEMATOMA OR ABSCESS SHOULDER","21000070","CDM","361","RC","23030","HCPCS",,,"facility","inpatient",,,,"20090","20090",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INCISION AND DRAINAGE HEMATOMA OR ABSCESS SHOULDER","21000070","CDM","361","RC","23030","HCPCS",,,"facility","outpatient",,,,"20090","20090",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM ELBOW","21000072","CDM","361","RC","24220","HCPCS",,,"facility","inpatient",,,,"3385","3385",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM ELBOW","21000072","CDM","361","RC","24220","HCPCS",,,"facility","outpatient",,,,"3385","3385",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM WRIST","21000073","CDM","361","RC","25246","HCPCS",,,"facility","inpatient",,,,"814","814",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM WRIST","21000073","CDM","361","RC","25246","HCPCS",,,"facility","outpatient",,,,"814","814",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE HIP/PELVIS AREA SUPERFICIAL","21000075","CDM","361","RC","27040","HCPCS",,,"facility","inpatient",,,,"5454","5454",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE HIP/PELVIS AREA SUPERFICIAL","21000075","CDM","361","RC","27040","HCPCS",,,"facility","outpatient",,,,"5454","5454",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE HIP/PELVIS AREA DEEP","21000076","CDM","361","RC","27041","HCPCS",,,"facility","inpatient",,,,"5244","5244",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE HIP/PELVIS AREA DEEP","21000076","CDM","361","RC","27041","HCPCS",,,"facility","outpatient",,,,"5244","5244",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE KNEE OR THIGH","21000079","CDM","361","RC","27323","HCPCS",,,"facility","inpatient",,,,"5441","5441",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE KNEE OR THIGH","21000079","CDM","361","RC","27323","HCPCS",,,"facility","outpatient",,,,"5441","5441",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM ANKLE","21000081","CDM","361","RC","27648","HCPCS",,,"facility","inpatient",,,,"3935","3935",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM ANKLE","21000081","CDM","361","RC","27648","HCPCS",,,"facility","outpatient",,,,"3935","3935",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTUBATION ENDOTRACHEAL","21000094","CDM","361","RC","31500","HCPCS",,,"facility","inpatient",,,,"1621","1621",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTUBATION ENDOTRACHEAL","21000094","CDM","361","RC","31500","HCPCS",,,"facility","outpatient",,,,"1621","1621",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRACHEOSTOMY TUBE CHANGE","21000095","CDM","361","RC","31502","HCPCS",,,"facility","inpatient",,,,"1675","1675",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRACHEOSTOMY TUBE CHANGE","21000095","CDM","361","RC","31502","HCPCS",,,"facility","outpatient",,,,"1675","1675",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LARYNGOSCOPY DIAGNOSTIC","21000096","CDM","361","RC","31575","HCPCS",,,"facility","inpatient",,,,"1102","1102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LARYNGOSCOPY DIAGNOSTIC","21000096","CDM","361","RC","31575","HCPCS",,,"facility","outpatient",,,,"1102","1102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRACH PUNCTURE W TRANSTRACH ASP/INJ","21000097","CDM","361","RC","31612","HCPCS",,,"facility","inpatient",,,,"9377","9377",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRACH PUNCTURE W TRANSTRACH ASP/INJ","21000097","CDM","361","RC","31612","HCPCS",,,"facility","outpatient",,,,"9377","9377",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRONCHOSCOPY DIAGNOSTIC","21000099","CDM","361","RC","31622","HCPCS",,,"facility","inpatient",,,,"9400","9400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRONCHOSCOPY DIAGNOSTIC","21000099","CDM","361","RC","31622","HCPCS",,,"facility","outpatient",,,,"9400","9400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERTION PLEURAL CATHETER","21000103","CDM","361","RC","32550","HCPCS",,,"facility","inpatient",,,,"11186","11186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERTION PLEURAL CATHETER","21000103","CDM","361","RC","32550","HCPCS",,,"facility","outpatient",,,,"11186","11186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY PLEURA","21000106","CDM","361","RC","32400","HCPCS",,,"facility","inpatient",,,,"5474","5474",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY PLEURA","21000106","CDM","361","RC","32400","HCPCS",,,"facility","outpatient",,,,"5474","5474",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER INSERTION OR REPLACEMENT WITH ELECTRODE ATRI","21000110","CDM","361","RC","33206","HCPCS",,,"facility","inpatient",,,,"33236","33236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER INSERTION OR REPLACEMENT WITH ELECTRODE ATRI","21000110","CDM","361","RC","33206","HCPCS",,,"facility","outpatient",,,,"33236","33236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER INSERTION OR REPLACEMENT WITH ELECTRODE VENT","21000111","CDM","361","RC","33207","HCPCS",,,"facility","inpatient",,,,"34103","34103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER INSERTION OR REPLACEMENT WITH ELECTRODE VENT","21000111","CDM","361","RC","33207","HCPCS",,,"facility","outpatient",,,,"34103","34103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER INSERTION OR REPLACEMENT WITH ELECTRODE ATRIAL AND VENTRICULAR","21000112","CDM","361","RC","33208","HCPCS",,,"facility","inpatient",,,,"40733","40733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER INSERTION OR REPLACEMENT WITH ELECTRODE ATRIAL AND VENTRICULAR","21000112","CDM","361","RC","33208","HCPCS",,,"facility","outpatient",,,,"40733","40733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TEMPORARY PACER INSERTION SINGLE","21000113","CDM","361","RC","33210","HCPCS",,,"facility","inpatient",,,,"18783","18783",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TEMPORARY PACER INSERTION SINGLE","21000113","CDM","361","RC","33210","HCPCS",,,"facility","outpatient",,,,"18783","18783",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TEMPORARY PACER INSERTION DUAL","21000114","CDM","361","RC","33211","HCPCS",,,"facility","inpatient",,,,"894","894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TEMPORARY PACER INSERTION DUAL","21000114","CDM","361","RC","33211","HCPCS",,,"facility","outpatient",,,,"894","894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER GENERATOR ONLY INSERTION OR REPLACEMENT SING","21000115","CDM","361","RC","33212","HCPCS",,,"facility","inpatient",,,,"17449","17449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER GENERATOR ONLY INSERTION OR REPLACEMENT SING","21000115","CDM","361","RC","33212","HCPCS",,,"facility","outpatient",,,,"17449","17449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER GENERATOR ONLY INSERTION OR REPLACEMENT DUAL","21000116","CDM","361","RC","33213","HCPCS",,,"facility","inpatient",,,,"41592","41592",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER GENERATOR ONLY INSERTION OR REPLACEMENT DUAL","21000116","CDM","361","RC","33213","HCPCS",,,"facility","outpatient",,,,"41592","41592",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER GENERATOR UPGRADE SINGLE CHAMBER TO DUAL CHA","21000117","CDM","361","RC","33214","HCPCS",,,"facility","inpatient",,,,"57092","57092",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER GENERATOR UPGRADE SINGLE CHAMBER TO DUAL CHA","21000117","CDM","361","RC","33214","HCPCS",,,"facility","outpatient",,,,"57092","57092",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPOSITION PREV IMP TRNSVNS PACER/ELECTRD","21000118","CDM","361","RC","33215","HCPCS",,,"facility","inpatient",,,,"12768","12768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPOSITION PREV IMP TRNSVNS PACER/ELECTRD","21000118","CDM","361","RC","33215","HCPCS",,,"facility","outpatient",,,,"12768","12768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT 1 TRANSVNS ELECTRODE PACER/IMP DEFIB","21000119","CDM","361","RC","33216","HCPCS",,,"facility","inpatient",,,,"18741","18741",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT 1 TRANSVNS ELECTRODE PACER/IMP DEFIB","21000119","CDM","361","RC","33216","HCPCS",,,"facility","outpatient",,,,"18741","18741",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT 2 TRANSVNS ELECTRODE PACER/IMP DEFIB","21000120","CDM","361","RC","33217","HCPCS",,,"facility","inpatient",,,,"33204","33204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT 2 TRANSVNS ELECTRODE PACER/IMP DEFIB","21000120","CDM","361","RC","33217","HCPCS",,,"facility","outpatient",,,,"33204","33204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR 1 TRNSVNS ELECTRODE PERM PACER/ICD","21000121","CDM","361","RC","33218","HCPCS",,,"facility","inpatient",,,,"23782","23782",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR 1 TRNSVNS ELECTRODE PERM PACER/ICD","21000121","CDM","361","RC","33218","HCPCS",,,"facility","outpatient",,,,"23782","23782",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR 2 TRNSVNS ELECTRODES PERM PACER/ICD","21000122","CDM","361","RC","33220","HCPCS",,,"facility","inpatient",,,,"3551","3551",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR 2 TRNSVNS ELECTRODES PERM PACER/ICD","21000122","CDM","361","RC","33220","HCPCS",,,"facility","outpatient",,,,"3551","3551",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER RELOCATION OF SKIN POCKET","21000123","CDM","361","RC","33222","HCPCS",,,"facility","inpatient",,,,"11324","11324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER RELOCATION OF SKIN POCKET","21000123","CDM","361","RC","33222","HCPCS",,,"facility","outpatient",,,,"11324","11324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ICD RELOCATION OF SKIN POCKET","21000124","CDM","361","RC","33223","HCPCS",,,"facility","inpatient",,,,"19304","19304",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ICD RELOCATION OF SKIN POCKET","21000124","CDM","361","RC","33223","HCPCS",,,"facility","outpatient",,,,"19304","19304",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT ELEC/CAR VN SYS PREV PLCD PCR/ICD GEN","21000125","CDM","361","RC","33224","HCPCS",,,"facility","inpatient",,,,"35251","35251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT ELEC/CAR VN SYS PREV PLCD PCR/ICD GEN","21000125","CDM","361","RC","33224","HCPCS",,,"facility","outpatient",,,,"35251","35251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT ELEC/CAR VN SYS AND PCR/ICD GEN SAME TIME","21000126","CDM","361","RC","33225","HCPCS",,,"facility","inpatient",,,,"32321","32321",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT ELEC/CAR VN SYS AND PCR/ICD GEN SAME TIME","21000126","CDM","361","RC","33225","HCPCS",,,"facility","outpatient",,,,"32321","32321",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEAD REPOSITION CORONARY SINUS/LV ON PREVIOUSLY IM","21000127","CDM","361","RC","33226","HCPCS",,,"facility","inpatient",,,,"5386","5386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEAD REPOSITION CORONARY SINUS/LV ON PREVIOUSLY IM","21000127","CDM","361","RC","33226","HCPCS",,,"facility","outpatient",,,,"5386","5386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER REMOVAL GENERATOR ONLY","21000128","CDM","361","RC","33233","HCPCS",,,"facility","inpatient",,,,"19731","19731",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACER REMOVAL GENERATOR ONLY","21000128","CDM","361","RC","33233","HCPCS",,,"facility","outpatient",,,,"19731","19731",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEAD REMOVAL SINGLE CHAMBER PACER","21000129","CDM","361","RC","33234","HCPCS",,,"facility","inpatient",,,,"14603","14603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEAD REMOVAL SINGLE CHAMBER PACER","21000129","CDM","361","RC","33234","HCPCS",,,"facility","outpatient",,,,"14603","14603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEAD REMOVAL DUAL CHAMBER PACER","21000130","CDM","361","RC","33235","HCPCS",,,"facility","inpatient",,,,"15449","15449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEAD REMOVAL DUAL CHAMBER PACER","21000130","CDM","361","RC","33235","HCPCS",,,"facility","outpatient",,,,"15449","15449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL IMP DEFIB PULSE GEN ONLY","21000131","CDM","361","RC","33241","HCPCS",,,"facility","inpatient",,,,"15291","15291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL IMP DEFIB PULSE GEN ONLY","21000131","CDM","361","RC","33241","HCPCS",,,"facility","outpatient",,,,"15291","15291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE SNGL/DUAL IMP DEFIB ELECTRDS TRNSVNS EXT","21000132","CDM","361","RC","33244","HCPCS",,,"facility","inpatient",,,,"13910","13910",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE SNGL/DUAL IMP DEFIB ELECTRDS TRNSVNS EXT","21000132","CDM","361","RC","33244","HCPCS",,,"facility","outpatient",,,,"13910","13910",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR TA DPLMNT AORT-ARTC TUB NDGFT COV LSA","21000135","CDM","361","RC","33880","HCPCS",,,"facility","inpatient",,,,"8470","8470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR TA DPLMNT AORT-ARTC TUB NDGFT COV LSA","21000135","CDM","361","RC","33880","HCPCS",,,"facility","outpatient",,,,"8470","8470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVAS RPR TA DPLMNT AORT-ARTC TUB NDGFT XCOV LSA","21000136","CDM","361","RC","33881","HCPCS",,,"facility","inpatient",,,,"7300","7300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVAS RPR TA DPLMNT AORT-ARTC TUB NDGFT XCOV LSA","21000136","CDM","361","RC","33881","HCPCS",,,"facility","outpatient",,,,"7300","7300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DLYD PLMT PROX XTN PROSTH NOT COV LSA ORIGIN","21000137","CDM","361","RC","33883","HCPCS",,,"facility","inpatient",,,,"6600","6600",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DLYD PLMT PROX XTN PROSTH NOT COV LSA ORIGIN","21000137","CDM","361","RC","33883","HCPCS",,,"facility","outpatient",,,,"6600","6600",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THORACIC AA ENDOVASCULAR PLACEMENT PROSTHESIS ADDITIONAL EXTENSION","21000138","CDM","361","RC","33884","HCPCS",,,"facility","inpatient",,,,"1725","1725",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THORACIC AA ENDOVASCULAR PLACEMENT PROSTHESIS ADDITIONAL EXTENSION","21000138","CDM","361","RC","33884","HCPCS",,,"facility","outpatient",,,,"1725","1725",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DLYD PLMT DSTL XTN PROSTH LVL LSA TO CELIAC ART","21000139","CDM","361","RC","33886","HCPCS",,,"facility","inpatient",,,,"4360","4360",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DLYD PLMT DSTL XTN PROSTH LVL LSA TO CELIAC ART","21000139","CDM","361","RC","33886","HCPCS",,,"facility","outpatient",,,,"4360","4360",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IABP INSERTION PERCUTANEOUSLY","21000140","CDM","361","RC","33967","HCPCS",,,"facility","inpatient",,,,"13273","13273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IABP INSERTION PERCUTANEOUSLY","21000140","CDM","361","RC","33967","HCPCS",,,"facility","outpatient",,,,"13273","13273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACEMENT ILIAC OCCLUSION DEVICE","21000145","CDM","361","RC","34808","HCPCS",,,"facility","inpatient",,,,"979","979",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACEMENT ILIAC OCCLUSION DEVICE","21000145","CDM","361","RC","34808","HCPCS",,,"facility","outpatient",,,,"979","979",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRODUCTION NEEDLE OR INTRACATHETER INTO VEIN","21000167","CDM","361","RC","36000","HCPCS",,,"facility","inpatient",,,,"603","603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRODUCTION NEEDLE OR INTRACATHETER INTO VEIN","21000167","CDM","361","RC","36000","HCPCS",,,"facility","outpatient",,,,"603","603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PSEUDOANEURYSM","21000168","CDM","361","RC","36002","HCPCS",,,"facility","inpatient",,,,"2295","2295",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PSEUDOANEURYSM","21000168","CDM","361","RC","36002","HCPCS",,,"facility","outpatient",,,,"2295","2295",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRODUCTION CATH SUPERIOR OR INFERIOR VENA CAVA","21000170","CDM","361","RC","36010","HCPCS",,,"facility","inpatient",,,,"5299","5299",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRODUCTION CATH SUPERIOR OR INFERIOR VENA CAVA","21000170","CDM","361","RC","36010","HCPCS",,,"facility","outpatient",,,,"5299","5299",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH VENOUS SYSTEM FIRST ORDER","21000171","CDM","361","RC","36011","HCPCS",,,"facility","inpatient",,,,"5740","5740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH VENOUS SYSTEM FIRST ORDER","21000171","CDM","361","RC","36011","HCPCS",,,"facility","outpatient",,,,"5740","5740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH VENOUS SYSTEM SECOND ORDER","21000172","CDM","361","RC","36012","HCPCS",,,"facility","inpatient",,,,"7556","7556",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH VENOUS SYSTEM SECOND ORDER","21000172","CDM","361","RC","36012","HCPCS",,,"facility","outpatient",,,,"7556","7556",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH RIGHT HEART OR MAIN PULMONARY ARTERY","21000173","CDM","361","RC","36013","HCPCS",,,"facility","inpatient",,,,"14978","14978",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH RIGHT HEART OR MAIN PULMONARY ARTERY","21000173","CDM","361","RC","36013","HCPCS",,,"facility","outpatient",,,,"14978","14978",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH LEFT OR RIGHT PULMONARY ARTERY","21000174","CDM","361","RC","36014","HCPCS",,,"facility","inpatient",,,,"7762","7762",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH LEFT OR RIGHT PULMONARY ARTERY","21000174","CDM","361","RC","36014","HCPCS",,,"facility","outpatient",,,,"7762","7762",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH SEGMENTAL OR SUBSEGMENTAL PULMONARY ARTERY","21000175","CDM","361","RC","36015","HCPCS",,,"facility","inpatient",,,,"35700","35700",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH SEGMENTAL OR SUBSEGMENTAL PULMONARY ARTERY","21000175","CDM","361","RC","36015","HCPCS",,,"facility","outpatient",,,,"35700","35700",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH CAROTID OR VERTEBRAL ARTERY","21000176","CDM","361","RC","36100","HCPCS",,,"facility","inpatient",,,,"4240","4240",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH CAROTID OR VERTEBRAL ARTERY","21000176","CDM","361","RC","36100","HCPCS",,,"facility","outpatient",,,,"4240","4240",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRO NEEDLE INTRACATH UPPR/LOWR EXTR ARTERY","21000178","CDM","361","RC","36140","HCPCS",,,"facility","inpatient",,,,"5300","5300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRO NEEDLE INTRACATH UPPR/LOWR EXTR ARTERY","21000178","CDM","361","RC","36140","HCPCS",,,"facility","outpatient",,,,"5300","5300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH AORTA TRANSLUMBAR","21000180","CDM","361","RC","36160","HCPCS",,,"facility","inpatient",,,,"4740","4740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH AORTA TRANSLUMBAR","21000180","CDM","361","RC","36160","HCPCS",,,"facility","outpatient",,,,"4740","4740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH AORTA","21000181","CDM","361","RC","36200","HCPCS",,,"facility","inpatient",,,,"6430","6430",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH AORTA","21000181","CDM","361","RC","36200","HCPCS",,,"facility","outpatient",,,,"6430","6430",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH THORACIC FIRST ORDER ARTERY","21000182","CDM","361","RC","36215","HCPCS",,,"facility","inpatient",,,,"7884","7884",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH THORACIC FIRST ORDER ARTERY","21000182","CDM","361","RC","36215","HCPCS",,,"facility","outpatient",,,,"7884","7884",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH THORACIC SECOND ORDER ARTERY","21000183","CDM","361","RC","36216","HCPCS",,,"facility","inpatient",,,,"8166","8166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH THORACIC SECOND ORDER ARTERY","21000183","CDM","361","RC","36216","HCPCS",,,"facility","outpatient",,,,"8166","8166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH THORACIC THIRD ORDER ARTERY","21000184","CDM","361","RC","36217","HCPCS",,,"facility","inpatient",,,,"10979","10979",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH THORACIC THIRD ORDER ARTERY","21000184","CDM","361","RC","36217","HCPCS",,,"facility","outpatient",,,,"10979","10979",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH THORACIC EACH ADDITIONAL ARTERY","21000185","CDM","361","RC","36218","HCPCS",,,"facility","inpatient",,,,"4713","4713",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH THORACIC EACH ADDITIONAL ARTERY","21000185","CDM","361","RC","36218","HCPCS",,,"facility","outpatient",,,,"4713","4713",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH ABDOMINAL, LOWER EXTREMITY, PELVIC FIRST ORDER ARTERY","21000186","CDM","361","RC","36245","HCPCS",,,"facility","inpatient",,,,"7790","7790",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH ABDOMINAL, LOWER EXTREMITY, PELVIC FIRST ORDER ARTERY","21000186","CDM","361","RC","36245","HCPCS",,,"facility","outpatient",,,,"7790","7790",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH ABDOMINAL, LOWER EXTREMITY, PELVIC SECOND ORDER ARTERY","21000187","CDM","361","RC","36246","HCPCS",,,"facility","inpatient",,,,"6941","6941",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH ABDOMINAL, LOWER EXTREMITY, PELVIC SECOND ORDER ARTERY","21000187","CDM","361","RC","36246","HCPCS",,,"facility","outpatient",,,,"6941","6941",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH ABDOMINAL, LOWER EXTREMITY, PELVIC THIRD ORDER ARTERY","21000188","CDM","361","RC","36247","HCPCS",,,"facility","inpatient",,,,"8301","8301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH ABDOMINAL, LOWER EXTREMITY, PELVIC THIRD ORDER ARTERY","21000188","CDM","361","RC","36247","HCPCS",,,"facility","outpatient",,,,"8301","8301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH ABDOMINAL, LOWER EXTREMITY, PELVIC EACH ADDITIONAL ARTERY","21000189","CDM","361","RC","36248","HCPCS",,,"facility","inpatient",,,,"5368","5368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH ABDOMINAL, LOWER EXTREMITY, PELVIC EACH ADDITIONAL ARTERY","21000189","CDM","361","RC","36248","HCPCS",,,"facility","outpatient",,,,"5368","5368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXCHANGE TRANSFUSION NEWBORN","21000190","CDM","391","RC","36450","HCPCS",,,"facility","inpatient",,,,"3005","3005",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXCHANGE TRANSFUSION NEWBORN","21000190","CDM","391","RC","36450","HCPCS",,,"facility","outpatient",,,,"3005","3005",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SCLEROSANT SINGLE VEIN OT TELANG","21000191","CDM","361","RC","36470","HCPCS",,,"facility","inpatient",,,,"1927","1927",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SCLEROSANT SINGLE VEIN OT TELANG","21000191","CDM","361","RC","36470","HCPCS",,,"facility","outpatient",,,,"1927","1927",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH PORTAL VEIN ANY METHOD","21000193","CDM","361","RC","36481","HCPCS",,,"facility","inpatient",,,,"3265","3265",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH PORTAL VEIN ANY METHOD","21000193","CDM","361","RC","36481","HCPCS",,,"facility","outpatient",,,,"3265","3265",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH VENOUS ORGAN BLOOD SAMPLING","21000194","CDM","361","RC","36500","HCPCS",,,"facility","inpatient",,,,"4548","4548",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELECTIVE CATH VENOUS ORGAN BLOOD SAMPLING","21000194","CDM","361","RC","36500","HCPCS",,,"facility","outpatient",,,,"4548","4548",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHOTOPHERESIS","21000195","CDM","361","RC","36522","HCPCS",,,"facility","inpatient",,,,"12821","12821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHOTOPHERESIS","21000195","CDM","361","RC","36522","HCPCS",,,"facility","outpatient",,,,"12821","12821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECLOT VASCULAR DEVICE WITH THROMBOLYTIC","21000197","CDM","361","RC","36593","HCPCS",,,"facility","inpatient",,,,"1307","1307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECLOT VASCULAR DEVICE WITH THROMBOLYTIC","21000197","CDM","361","RC","36593","HCPCS",,,"facility","outpatient",,,,"1307","1307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATH INSERTION NON-TUNNELED LESS THAN 5YR","21000198","CDM","361","RC","36555","HCPCS",,,"facility","inpatient",,,,"1485","1485",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATH INSERTION NON-TUNNELED LESS THAN 5YR","21000198","CDM","361","RC","36555","HCPCS",,,"facility","outpatient",,,,"1485","1485",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATH INSERTION NON-TUNNELED 5YR OR OLDER","21000199","CDM","361","RC","36556","HCPCS",,,"facility","inpatient",,,,"4508","4508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATH INSERTION NON-TUNNELED 5YR OR OLDER","21000199","CDM","361","RC","36556","HCPCS",,,"facility","outpatient",,,,"4508","4508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CV CATHETER INSERTION TUNNELED WITHOUT PORT LESS THAN 5 YR","21000200","CDM","361","RC","36557","HCPCS",,,"facility","inpatient",,,,"10081","10081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CV CATHETER INSERTION TUNNELED WITHOUT PORT LESS THAN 5 YR","21000200","CDM","361","RC","36557","HCPCS",,,"facility","outpatient",,,,"10081","10081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CV CATHETER INSERTION TUNNELED WITHOUT PORT 5 YR OR OLDER","21000201","CDM","361","RC","36558","HCPCS",,,"facility","inpatient",,,,"12097","12097",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CV CATHETER INSERTION TUNNELED WITHOUT PORT 5 YR OR OLDER","21000201","CDM","361","RC","36558","HCPCS",,,"facility","outpatient",,,,"12097","12097",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER INSERTION TUNNELED WITH PORT LESS THAN 5 YR","21000202","CDM","361","RC","36560","HCPCS",,,"facility","inpatient",,,,"14959","14959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER INSERTION TUNNELED WITH PORT LESS THAN 5 YR","21000202","CDM","361","RC","36560","HCPCS",,,"facility","outpatient",,,,"14959","14959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER INSERTION TUNNELED WITH PORT 5 YR OR OLDER","21000203","CDM","361","RC","36561","HCPCS",,,"facility","inpatient",,,,"15158","15158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER INSERTION TUNNELED WITH PORT 5 YR OR OLDER","21000203","CDM","361","RC","36561","HCPCS",,,"facility","outpatient",,,,"15158","15158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CV ACCESS DEVICE INSERTION TUNNELED REQUIRING 2 CATHETERS W/ 2 SITES W/OUT PORT","21000204","CDM","361","RC","36565","HCPCS",,,"facility","inpatient",,,,"7516","7516",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CV ACCESS DEVICE INSERTION TUNNELED REQUIRING 2 CATHETERS W/ 2 SITES W/OUT PORT","21000204","CDM","361","RC","36565","HCPCS",,,"facility","outpatient",,,,"7516","7516",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS ACCESS DEVICE INSERTION TUNNELED REQ 2 CATH W/ 2 SITES WITH PORT","21000205","CDM","361","RC","36566","HCPCS",,,"facility","inpatient",,,,"529","529",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS ACCESS DEVICE INSERTION TUNNELED REQ 2 CATH W/ 2 SITES WITH PORT","21000205","CDM","361","RC","36566","HCPCS",,,"facility","outpatient",,,,"529","529",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PICC INSERTION WITH PORT LESS THAN 5 YR","21000208","CDM","361","RC","36570","HCPCS",,,"facility","inpatient",,,,"11311","11311",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PICC INSERTION WITH PORT LESS THAN 5 YR","21000208","CDM","361","RC","36570","HCPCS",,,"facility","outpatient",,,,"11311","11311",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PICC INSERTION WITH PORT 5 YR OR OLDER","21000209","CDM","361","RC","36571","HCPCS",,,"facility","inpatient",,,,"17215","17215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PICC INSERTION WITH PORT 5 YR OR OLDER","21000209","CDM","361","RC","36571","HCPCS",,,"facility","outpatient",,,,"17215","17215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPAIR WITHOUT PORT","21000210","CDM","361","RC","36575","HCPCS",,,"facility","inpatient",,,,"3942","3942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPAIR WITHOUT PORT","21000210","CDM","361","RC","36575","HCPCS",,,"facility","outpatient",,,,"3942","3942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS ACCESS REPLACEMENT CATH WITH PORT","21000211","CDM","361","RC","36578","HCPCS",,,"facility","inpatient",,,,"6757","6757",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS ACCESS REPLACEMENT CATH WITH PORT","21000211","CDM","361","RC","36578","HCPCS",,,"facility","outpatient",,,,"6757","6757",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPLACEMENT NON-TUNNELED","21000212","CDM","361","RC","36580","HCPCS",,,"facility","inpatient",,,,"12100","12100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPLACEMENT NON-TUNNELED","21000212","CDM","361","RC","36580","HCPCS",,,"facility","outpatient",,,,"12100","12100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPLACEMENT TUNNELED","21000213","CDM","361","RC","36581","HCPCS",,,"facility","inpatient",,,,"10190","10190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPLACEMENT TUNNELED","21000213","CDM","361","RC","36581","HCPCS",,,"facility","outpatient",,,,"10190","10190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPLACEMENT TUNNELED WITH PORT","21000214","CDM","361","RC","36582","HCPCS",,,"facility","inpatient",,,,"15826","15826",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPLACEMENT TUNNELED WITH PORT","21000214","CDM","361","RC","36582","HCPCS",,,"facility","outpatient",,,,"15826","15826",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPLACEMENT TUNNELED WITH PUMP","21000215","CDM","361","RC","36583","HCPCS",,,"facility","inpatient",,,,"21158","21158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPLACEMENT TUNNELED WITH PUMP","21000215","CDM","361","RC","36583","HCPCS",,,"facility","outpatient",,,,"21158","21158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE PICC WO PORT SAME ACCESS W/ S&I","21000217","CDM","361","RC","36584","HCPCS",,,"facility","inpatient",,,,"4578","4578",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE PICC WO PORT SAME ACCESS W/ S&I","21000217","CDM","361","RC","36584","HCPCS",,,"facility","outpatient",,,,"4578","4578",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PICC REPLACEMENT WITH PORT","21000218","CDM","361","RC","36585","HCPCS",,,"facility","inpatient",,,,"7204","7204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PICC REPLACEMENT WITH PORT","21000218","CDM","361","RC","36585","HCPCS",,,"facility","outpatient",,,,"7204","7204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER TUNNELED REMOVAL","21000219","CDM","361","RC","36589","HCPCS",,,"facility","inpatient",,,,"4713","4713",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER TUNNELED REMOVAL","21000219","CDM","361","RC","36589","HCPCS",,,"facility","outpatient",,,,"4713","4713",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER TUNNELED REMOVAL WITH PORT","21000220","CDM","361","RC","36590","HCPCS",,,"facility","inpatient",,,,"8425","8425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER TUNNELED REMOVAL WITH PORT","21000220","CDM","361","RC","36590","HCPCS",,,"facility","outpatient",,,,"8425","8425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL PERICATHETER OBSTRUCTIVE MATERIAL","21000221","CDM","361","RC","36595","HCPCS",,,"facility","inpatient",,,,"7095","7095",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL PERICATHETER OBSTRUCTIVE MATERIAL","21000221","CDM","361","RC","36595","HCPCS",,,"facility","outpatient",,,,"7095","7095",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECLOT VASCULAR DEVICE MECHANICAL","21000222","CDM","361","RC","36596","HCPCS",,,"facility","inpatient",,,,"288","288",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECLOT VASCULAR DEVICE MECHANICAL","21000222","CDM","361","RC","36596","HCPCS",,,"facility","outpatient",,,,"288","288",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPOSITIONING UNDER FLUORO","21000223","CDM","361","RC","36597","HCPCS",,,"facility","inpatient",,,,"5682","5682",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS CATHETER REPOSITIONING UNDER FLUORO","21000223","CDM","361","RC","36597","HCPCS",,,"facility","outpatient",,,,"5682","5682",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS ACCESS INJECTION WITH FLUORO","21000224","CDM","361","RC","36598","HCPCS",,,"facility","inpatient",,,,"1331","1331",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CENTRAL VENOUS ACCESS INJECTION WITH FLUORO","21000224","CDM","361","RC","36598","HCPCS",,,"facility","outpatient",,,,"1331","1331",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ARTERIAL CATHETERIZATION","21000225","CDM","361","RC","36620","HCPCS",,,"facility","inpatient",,,,"1687","1687",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ARTERIAL CATHETERIZATION","21000225","CDM","361","RC","36620","HCPCS",,,"facility","outpatient",,,,"1687","1687",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMODIALYSIS CANNULA INSERTION VEIN TO VEIN","21000226","CDM","361","RC","36800","HCPCS",,,"facility","inpatient",,,,"1047","1047",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMODIALYSIS CANNULA INSERTION VEIN TO VEIN","21000226","CDM","361","RC","36800","HCPCS",,,"facility","outpatient",,,,"1047","1047",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN REVISION AV FISTULA WITH THROMBECTOMY","21000227","CDM","361","RC","36833","HCPCS",,,"facility","inpatient",,,,"44643","44643",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN REVISION AV FISTULA WITH THROMBECTOMY","21000227","CDM","361","RC","36833","HCPCS",,,"facility","outpatient",,,,"44643","44643",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECLOT EXTERNAL CANNULA WITH BALLOON","21000229","CDM","361","RC","36861","HCPCS",,,"facility","inpatient",,,,"10532","10532",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECLOT EXTERNAL CANNULA WITH BALLOON","21000229","CDM","361","RC","36861","HCPCS",,,"facility","outpatient",,,,"10532","10532",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN VENOUS ANASTOMOSIS PORTACAVAL","21000231","CDM","361","RC","37140","HCPCS",,,"facility","inpatient",,,,"9618","9618",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN VENOUS ANASTOMOSIS PORTACAVAL","21000231","CDM","361","RC","37140","HCPCS",,,"facility","outpatient",,,,"9618","9618",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIPS INSERTION","21000232","CDM","361","RC","37182","HCPCS",,,"facility","inpatient",,,,"13246","13246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIPS INSERTION","21000232","CDM","361","RC","37182","HCPCS",,,"facility","outpatient",,,,"13246","13246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIPS REVISION","21000233","CDM","361","RC","37183","HCPCS",,,"facility","inpatient",,,,"20596","20596",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIPS REVISION","21000233","CDM","361","RC","37183","HCPCS",,,"facility","outpatient",,,,"20596","20596",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBECTOMY ARTERIAL INITIAL","21000234","CDM","361","RC","37184","HCPCS",,,"facility","inpatient",,,,"21446","21446",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBECTOMY ARTERIAL INITIAL","21000234","CDM","361","RC","37184","HCPCS",,,"facility","outpatient",,,,"21446","21446",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBECTOMY ARTERIAL SECOND AND SUBSEQUENT VESSELS IN SAME VASCULAR FAMILY","21000235","CDM","361","RC","37185","HCPCS",,,"facility","inpatient",,,,"12572","12572",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBECTOMY ARTERIAL SECOND AND SUBSEQUENT VESSELS IN SAME VASCULAR FAMILY","21000235","CDM","361","RC","37185","HCPCS",,,"facility","outpatient",,,,"12572","12572",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBCTMY SCNDRY PRC W FLUORO/INJ ADD ON","21000236","CDM","361","RC","37186","HCPCS",,,"facility","inpatient",,,,"9727","9727",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBCTMY SCNDRY PRC W FLUORO/INJ ADD ON","21000236","CDM","361","RC","37186","HCPCS",,,"facility","outpatient",,,,"9727","9727",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBECTOMY MECHANICAL VENOUS WITH FLUORO","21000237","CDM","361","RC","37187","HCPCS",,,"facility","inpatient",,,,"21467","21467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBECTOMY MECHANICAL VENOUS WITH FLUORO","21000237","CDM","361","RC","37187","HCPCS",,,"facility","outpatient",,,,"21467","21467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MECHANICAL THROMBECTOMY VEIN SUBSEQUENT TREATMENT","21000238","CDM","361","RC","37188","HCPCS",,,"facility","inpatient",,,,"30467","30467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MECHANICAL THROMBECTOMY VEIN SUBSEQUENT TREATMENT","21000238","CDM","361","RC","37188","HCPCS",,,"facility","outpatient",,,,"30467","30467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBOLYSIS CEREBRAL BY INTRAVENOUS INFUSION","21000239","CDM","361","RC","37195","HCPCS",,,"facility","inpatient",,,,"2021","2021",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBOLYSIS CEREBRAL BY INTRAVENOUS INFUSION","21000239","CDM","361","RC","37195","HCPCS",,,"facility","outpatient",,,,"2021","2021",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY TRANSCATHETER","21000240","CDM","361","RC","37200","HCPCS",,,"facility","inpatient",,,,"11710","11710",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY TRANSCATHETER","21000240","CDM","361","RC","37200","HCPCS",,,"facility","outpatient",,,,"11710","11710",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT TRANSCATH CCA OPN/PRQ W DEP INCLDS ANGIO","21000251","CDM","361","RC","37215","HCPCS",,,"facility","inpatient",,,,"32603","32603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT TRANSCATH CCA OPN/PRQ W DEP INCLDS ANGIO","21000251","CDM","361","RC","37215","HCPCS",,,"facility","outpatient",,,,"32603","32603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT TRANSCATH CCA OPN/PRQ WO DEP INCLDS ANGIO","21000252","CDM","361","RC","37216","HCPCS",,,"facility","inpatient",,,"GY","6414","6414",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG STENT TRANSCATH CCA OPN/PRQ WO DEP INCLDS ANGIO","21000252","CDM","361","RC","37216","HCPCS",,,"facility","outpatient",,,"GY","6414","6414",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG INJECTION SPLENOPORTOGRAM","21000256","CDM","361","RC","38200","HCPCS",,,"facility","inpatient",,,,"616","616",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SPLENOPORTOGRAM","21000256","CDM","361","RC","38200","HCPCS",,,"facility","outpatient",,,,"616","616",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIAGNOSTIC BONE MARROW ASPIRATION","21000259","CDM","510","RC","38220","HCPCS",,,"facility","inpatient",,,,"5120","5120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIAGNOSTIC BONE MARROW ASPIRATION","21000259","CDM","510","RC","38220","HCPCS",,,"facility","outpatient",,,,"5120","5120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIAGNOSTIC BONE MARROW BIOPSY","21000260","CDM","361","RC","38221","HCPCS",,,"facility","inpatient",,,,"4081","4081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIAGNOSTIC BONE MARROW BIOPSY","21000260","CDM","361","RC","38221","HCPCS",,,"facility","outpatient",,,,"4081","4081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY OR EXCISION LYMPH NODE OPEN","21000261","CDM","361","RC","38500","HCPCS",,,"facility","inpatient",,,,"12887","12887",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY OR EXCISION LYMPH NODE OPEN","21000261","CDM","361","RC","38500","HCPCS",,,"facility","outpatient",,,,"12887","12887",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY LYMPH NODE SUPERFICIAL","21000262","CDM","361","RC","38505","HCPCS",,,"facility","inpatient",,,,"4436","4436",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY LYMPH NODE SUPERFICIAL","21000262","CDM","361","RC","38505","HCPCS",,,"facility","outpatient",,,,"4436","4436",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION LYMPHANGIOGRAPHY","21000263","CDM","361","RC","38790","HCPCS",,,"facility","inpatient",,,,"581","581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION LYMPHANGIOGRAPHY","21000263","CDM","361","RC","38790","HCPCS",,,"facility","outpatient",,,,"581","581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PROCEDURE FOR SENTINEL NODE","21000264","CDM","361","RC","38792","HCPCS",,,"facility","inpatient",,,,"3624","3624",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PROCEDURE FOR SENTINEL NODE","21000264","CDM","361","RC","38792","HCPCS",,,"facility","outpatient",,,,"3624","3624",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SIALOGRAM","21000266","CDM","361","RC","42550","HCPCS",,,"facility","inpatient",,,,"1542","1542",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SIALOGRAM","21000266","CDM","361","RC","42550","HCPCS",,,"facility","outpatient",,,,"1542","1542",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DILATION OF ESOPHAGUS OVER GUIDE WIRE","21000270","CDM","361","RC","43453","HCPCS",,,"facility","inpatient",,,,"10254","10254",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DILATION OF ESOPHAGUS OVER GUIDE WIRE","21000270","CDM","361","RC","43453","HCPCS",,,"facility","outpatient",,,,"10254","10254",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NG TUBE PLACEMENT WITH FLUOROSCOPY","21000273","CDM","361","RC","43752","HCPCS",,,"facility","inpatient",,,,"1668","1668",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NG TUBE PLACEMENT WITH FLUOROSCOPY","21000273","CDM","361","RC","43752","HCPCS",,,"facility","outpatient",,,,"1668","1668",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTROSTOMY TUBE REPOSITIONING","21000275","CDM","361","RC","43761","HCPCS",,,"facility","inpatient",,,,"3125","3125",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTROSTOMY TUBE REPOSITIONING","21000275","CDM","361","RC","43761","HCPCS",,,"facility","outpatient",,,,"3125","3125",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LAPAROSCOPIC REVISION OF ADJUSTABLE GASTRIC BAND","21000276","CDM","361","RC","43771","HCPCS",,,"facility","inpatient",,,,"6982","6982",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LAPAROSCOPIC REVISION OF ADJUSTABLE GASTRIC BAND","21000276","CDM","361","RC","43771","HCPCS",,,"facility","outpatient",,,,"6982","6982",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG JEJUNOSTOMY TUBE PLACEMENT FOR ENTERAL ALIMENTATION","21000277","CDM","361","RC","44015","HCPCS",,,"facility","inpatient",,,,"624","624",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG JEJUNOSTOMY TUBE PLACEMENT FOR ENTERAL ALIMENTATION","21000277","CDM","361","RC","44015","HCPCS",,,"facility","outpatient",,,,"624","624",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTROINTESTINAL TUBE INSERTION (MILLER ABBOTT)","21000281","CDM","361","RC","44500","HCPCS",,,"facility","inpatient",,,,"1833","1833",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTROINTESTINAL TUBE INSERTION (MILLER ABBOTT)","21000281","CDM","361","RC","44500","HCPCS",,,"facility","outpatient",,,,"1833","1833",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY LIVER WITH OTHER MAJOR PROCEDURE","21000286","CDM","361","RC","47001","HCPCS",,,"facility","inpatient",,,,"5712","5712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY LIVER WITH OTHER MAJOR PROCEDURE","21000286","CDM","361","RC","47001","HCPCS",,,"facility","outpatient",,,,"5712","5712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLATION LIVER TUMOR/S RADIOFREQUENCY PERCUTANEOUS","21000290","CDM","361","RC","47382","HCPCS",,,"facility","inpatient",,,,"15335","15335",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLATION LIVER TUMOR/S RADIOFREQUENCY PERCUTANEOUS","21000290","CDM","361","RC","47382","HCPCS",,,"facility","outpatient",,,,"15335","15335",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INCISION GALLBLADDER PERCUTANEOUS","21000291","CDM","361","RC","47490","HCPCS",,,"facility","inpatient",,,,"9807","9807",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INCISION GALLBLADDER PERCUTANEOUS","21000291","CDM","361","RC","47490","HCPCS",,,"facility","outpatient",,,,"9807","9807",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIARY ENDOSCOPY STONE REMOVAL","21000298","CDM","361","RC","47554","HCPCS",,,"facility","inpatient",,,,"5272","5272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIARY ENDOSCOPY STONE REMOVAL","21000298","CDM","361","RC","47554","HCPCS",,,"facility","outpatient",,,,"5272","5272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIARY ENDOSCOPY WITH DILATATION","21000299","CDM","361","RC","47555","HCPCS",,,"facility","inpatient",,,,"2169","2169",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIARY ENDOSCOPY WITH DILATATION","21000299","CDM","361","RC","47555","HCPCS",,,"facility","outpatient",,,,"2169","2169",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIARY ENDOSCOPY WITH DILATION WITH STENT PLACEMENT","21000300","CDM","361","RC","47556","HCPCS",,,"facility","inpatient",,,,"1986","1986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIARY ENDOSCOPY WITH DILATION WITH STENT PLACEMENT","21000300","CDM","361","RC","47556","HCPCS",,,"facility","outpatient",,,,"1986","1986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY PANCREAS","21000302","CDM","361","RC","48102","HCPCS",,,"facility","inpatient",,,,"4692","4692",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY PANCREAS","21000302","CDM","361","RC","48102","HCPCS",,,"facility","outpatient",,,,"4692","4692",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY ABDOMINAL/RETROPERITONEAL MASS","21000309","CDM","361","RC","49180","HCPCS",,,"facility","inpatient",,,,"4415","4415",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY ABDOMINAL/RETROPERITONEAL MASS","21000309","CDM","361","RC","49180","HCPCS",,,"facility","outpatient",,,,"4415","4415",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRAPERITONEAL DIALYSIS CATHETER OR CANNULA REMOVAL PERMANENT","21000312","CDM","361","RC","49422","HCPCS",,,"facility","inpatient",,,,"13376","13376",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRAPERITONEAL DIALYSIS CATHETER OR CANNULA REMOVAL PERMANENT","21000312","CDM","361","RC","49422","HCPCS",,,"facility","outpatient",,,,"13376","13376",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAINAGE CATHETER EXCHANGE","21000313","CDM","361","RC","49423","HCPCS",,,"facility","inpatient",,,,"6237","6237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAINAGE CATHETER EXCHANGE","21000313","CDM","361","RC","49423","HCPCS",,,"facility","outpatient",,,,"6237","6237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION CONTRAST TO ASSESS ABSCESS","21000314","CDM","361","RC","49424","HCPCS",,,"facility","inpatient",,,,"1213","1213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION CONTRAST TO ASSESS ABSCESS","21000314","CDM","361","RC","49424","HCPCS",,,"facility","outpatient",,,,"1213","1213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION VP SHUNT","21000315","CDM","361","RC","49427","HCPCS",,,"facility","inpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION VP SHUNT","21000315","CDM","361","RC","49427","HCPCS",,,"facility","outpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KIDNEY STONE REMOVAL UP TO 2 CM","21000318","CDM","361","RC","50080","HCPCS",,,"facility","inpatient",,,,"39022","39022",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KIDNEY STONE REMOVAL UP TO 2 CM","21000318","CDM","361","RC","50080","HCPCS",,,"facility","outpatient",,,,"39022","39022",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY RENAL","21000319","CDM","361","RC","50200","HCPCS",,,"facility","inpatient",,,,"4356","4356",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY RENAL","21000319","CDM","361","RC","50200","HCPCS",,,"facility","outpatient",,,,"4356","4356",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEPHROSTOMY TUBE REMOVAL WITH FLUORO","21000320","CDM","361","RC","50389","HCPCS",,,"facility","inpatient",,,,"5609","5609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEPHROSTOMY TUBE REMOVAL WITH FLUORO","21000320","CDM","361","RC","50389","HCPCS",,,"facility","outpatient",,,,"5609","5609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION RENAL CYST","21000321","CDM","361","RC","50390","HCPCS",,,"facility","inpatient",,,,"3897","3897",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION RENAL CYST","21000321","CDM","361","RC","50390","HCPCS",,,"facility","outpatient",,,,"3897","3897",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEPHROSTOMY TUBE MANOMETRY","21000326","CDM","361","RC","50396","HCPCS",,,"facility","inpatient",,,,"774","774",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEPHROSTOMY TUBE MANOMETRY","21000326","CDM","361","RC","50396","HCPCS",,,"facility","outpatient",,,,"774","774",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RENAL ENDOSCOPY WITH URETERAL CATHETERIZATION","21000328","CDM","361","RC","50553","HCPCS",,,"facility","inpatient",,,,"3238","3238",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RENAL ENDOSCOPY WITH URETERAL CATHETERIZATION","21000328","CDM","361","RC","50553","HCPCS",,,"facility","outpatient",,,,"3238","3238",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLATION RENAL TUMOR/S PERC UNILATERAL RF","21000329","CDM","361","RC","50592","HCPCS",,,"facility","inpatient",,,,"15220","15220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLATION RENAL TUMOR/S PERC UNILATERAL RF","21000329","CDM","361","RC","50592","HCPCS",,,"facility","outpatient",,,,"15220","15220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION URETEROGRAPHY OR PYELOGRAPHY","21000330","CDM","361","RC","50684","HCPCS",,,"facility","inpatient",,,,"1728","1728",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION URETEROGRAPHY OR PYELOGRAPHY","21000330","CDM","361","RC","50684","HCPCS",,,"facility","outpatient",,,,"1728","1728",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URETEROSTOMY TUBE OR URETERAL STENT CHANGE","21000331","CDM","361","RC","50688","HCPCS",,,"facility","inpatient",,,,"12252","12252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URETEROSTOMY TUBE OR URETERAL STENT CHANGE","21000331","CDM","361","RC","50688","HCPCS",,,"facility","outpatient",,,,"12252","12252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ILEAL CONDUIT","21000332","CDM","361","RC","50690","HCPCS",,,"facility","inpatient",,,,"3055","3055",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ILEAL CONDUIT","21000332","CDM","361","RC","50690","HCPCS",,,"facility","outpatient",,,,"3055","3055",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION BLADDER WITH INSERTION SUPRAPUBIC CATHETER","21000333","CDM","361","RC","51102","HCPCS",,,"facility","inpatient",,,,"9735","9735",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION BLADDER WITH INSERTION SUPRAPUBIC CATHETER","21000333","CDM","361","RC","51102","HCPCS",,,"facility","outpatient",,,,"9735","9735",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION CYSTOGRAM/VCUG","21000334","CDM","361","RC","51600","HCPCS",,,"facility","inpatient",,,,"1219","1219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION CYSTOGRAM/VCUG","21000334","CDM","361","RC","51600","HCPCS",,,"facility","outpatient",,,,"1219","1219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION RETROGRADE CYSTO","21000335","CDM","361","RC","51610","HCPCS",,,"facility","inpatient",,,,"1792","1792",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION RETROGRADE CYSTO","21000335","CDM","361","RC","51610","HCPCS",,,"facility","outpatient",,,,"1792","1792",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT STRAIGHT CATHETER","21000337","CDM","361","RC","51701","HCPCS",,,"facility","inpatient",,,,"681","681",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT STRAIGHT CATHETER","21000337","CDM","361","RC","51701","HCPCS",,,"facility","outpatient",,,,"681","681",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERTION FOLEY CATHETER","21000338","CDM","361","RC","51702","HCPCS",,,"facility","inpatient",,,,"768","768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERTION FOLEY CATHETER","21000338","CDM","361","RC","51702","HCPCS",,,"facility","outpatient",,,,"768","768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERTION FOLEY CATHETER COMPLEX","21000339","CDM","361","RC","51703","HCPCS",,,"facility","inpatient",,,,"965","965",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERTION FOLEY CATHETER COMPLEX","21000339","CDM","361","RC","51703","HCPCS",,,"facility","outpatient",,,,"965","965",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTOMETROGRAM COMPLEX","21000343","CDM","361","RC","51726","HCPCS",,,"facility","inpatient",,,,"1800","1800",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTOMETROGRAM COMPLEX","21000343","CDM","361","RC","51726","HCPCS",,,"facility","outpatient",,,,"1800","1800",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URODYNAMICS POST VOIDING URING","21000352","CDM","361","RC","51798","HCPCS",,,"facility","inpatient",,,,"511","511",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URODYNAMICS POST VOIDING URING","21000352","CDM","361","RC","51798","HCPCS",,,"facility","outpatient",,,,"511","511",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTOSCOPY WITH URETERAL CATHETERIZATION","21000354","CDM","361","RC","52005","HCPCS",,,"facility","inpatient",,,,"16506","16506",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTOSCOPY WITH URETERAL CATHETERIZATION","21000354","CDM","361","RC","52005","HCPCS",,,"facility","outpatient",,,,"16506","16506",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEPHROSTOMY","21000357","CDM","361","RC","52334","HCPCS",,,"facility","inpatient",,,,"1292","1292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEPHROSTOMY","21000357","CDM","361","RC","52334","HCPCS",,,"facility","outpatient",,,,"1292","1292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CIRCUMCISION NEWBORN","21000359","CDM","723","RC","54150","HCPCS",,,"facility","inpatient",,,,"484","484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CIRCUMCISION NEWBORN","21000359","CDM","723","RC","54150","HCPCS",,,"facility","outpatient",,,,"484","484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION CORPORA CAVERNOSOGRAPHY","21000360","CDM","361","RC","54230","HCPCS",,,"facility","inpatient",,,,"757","757",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION CORPORA CAVERNOSOGRAPHY","21000360","CDM","361","RC","54230","HCPCS",,,"facility","outpatient",,,,"757","757",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY PROSTATE","21000362","CDM","361","RC","55700","HCPCS",,,"facility","inpatient",,,,"9221","9221",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY PROSTATE","21000362","CDM","361","RC","55700","HCPCS",,,"facility","outpatient",,,,"9221","9221",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE RADIATION THERAPY DEVICE PROSTHETIC","21000363","CDM","361","RC","55876","HCPCS",,,"facility","inpatient",,,,"8956","8956",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE RADIATION THERAPY DEVICE PROSTHETIC","21000363","CDM","361","RC","55876","HCPCS",,,"facility","outpatient",,,,"8956","8956",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION HYSTEROSONOGRAM/SALPINGOGRAPY","21000371","CDM","361","RC","58340","HCPCS",,,"facility","inpatient",,,,"874","874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION HYSTEROSONOGRAM/SALPINGOGRAPY","21000371","CDM","361","RC","58340","HCPCS",,,"facility","outpatient",,,,"874","874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FALLOPIAN TUBE CATHETERIZATION","21000372","CDM","361","RC","58345","HCPCS",,,"facility","inpatient",,,,"2355","2355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FALLOPIAN TUBE CATHETERIZATION","21000372","CDM","361","RC","58345","HCPCS",,,"facility","outpatient",,,,"2355","2355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMNIOCENTESIS","21000375","CDM","361","RC","59000","HCPCS",,,"facility","inpatient",,,,"1105","1105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMNIOCENTESIS","21000375","CDM","361","RC","59000","HCPCS",,,"facility","outpatient",,,,"1105","1105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMNIOINFUSION","21000377","CDM","361","RC","59070","HCPCS",,,"facility","inpatient",,,,"1069","1069",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMNIOINFUSION","21000377","CDM","361","RC","59070","HCPCS",,,"facility","outpatient",,,,"1069","1069",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EPISIOTOMY OR VAGINAL REPAIR","21000378","CDM","361","RC","59300","HCPCS",,,"facility","inpatient",,,,"7869","7869",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EPISIOTOMY OR VAGINAL REPAIR","21000378","CDM","361","RC","59300","HCPCS",,,"facility","outpatient",,,,"7869","7869",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXTERNAL VERSION","21000379","CDM","361","RC","59412","HCPCS",,,"facility","inpatient",,,,"2750","2750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXTERNAL VERSION","21000379","CDM","361","RC","59412","HCPCS",,,"facility","outpatient",,,,"2750","2750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MULTIFETAL PREGNANCY REDUCTIONS","21000380","CDM","361","RC","59866","HCPCS",,,"facility","inpatient",,,,"1088","1088",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MULTIFETAL PREGNANCY REDUCTIONS","21000380","CDM","361","RC","59866","HCPCS",,,"facility","outpatient",,,,"1088","1088",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION OR INJECTION THYROID CYST","21000381","CDM","361","RC","60300","HCPCS",,,"facility","inpatient",,,,"2477","2477",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION OR INJECTION THYROID CYST","21000381","CDM","361","RC","60300","HCPCS",,,"facility","outpatient",,,,"2477","2477",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY THYROID","21000382","CDM","361","RC","60100","HCPCS",,,"facility","inpatient",,,,"2736","2736",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY THYROID","21000382","CDM","361","RC","60100","HCPCS",,,"facility","outpatient",,,,"2736","2736",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C1-C2 PUNCTURE W INJ MEDICATION","21000384","CDM","361","RC","61055","HCPCS",,,"facility","inpatient",,,,"2671","2671",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C1-C2 PUNCTURE W INJ MEDICATION","21000384","CDM","361","RC","61055","HCPCS",,,"facility","outpatient",,,,"2671","2671",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION OR INJECTION SHUNT","21000385","CDM","361","RC","61070","HCPCS",,,"facility","inpatient",,,,"4540","4540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION OR INJECTION SHUNT","21000385","CDM","361","RC","61070","HCPCS",,,"facility","outpatient",,,,"4540","4540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASCULAR TEMPORARY OCCLUSION HEAD OR NECK","21000386","CDM","361","RC","61623","HCPCS",,,"facility","inpatient",,,,"6820","6820",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASCULAR TEMPORARY OCCLUSION HEAD OR NECK","21000386","CDM","361","RC","61623","HCPCS",,,"facility","outpatient",,,,"6820","6820",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASCULAR PERMANENT OCCLUSION CNS","21000387","CDM","361","RC","61624","HCPCS",,,"facility","inpatient",,,,"29012","29012",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASCULAR PERMANENT OCCLUSION CNS","21000387","CDM","361","RC","61624","HCPCS",,,"facility","outpatient",,,,"29012","29012",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASCULAR PERMANENT OCCLUSION NON CNS HEAD OR NECK","21000388","CDM","361","RC","61626","HCPCS",,,"facility","inpatient",,,,"34381","34381",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASCULAR PERMANENT OCCLUSION NON CNS HEAD OR NECK","21000388","CDM","361","RC","61626","HCPCS",,,"facility","outpatient",,,,"34381","34381",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PTA INTRACRANIAL","21000389","CDM","361","RC","61630","HCPCS",,,"facility","inpatient",,,,"27860","27860",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PTA INTRACRANIAL","21000389","CDM","361","RC","61630","HCPCS",,,"facility","outpatient",,,,"27860","27860",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PTA INTRACRANIAL WITH STENT","21000390","CDM","361","RC","61635","HCPCS",,,"facility","inpatient",,,,"21204","21204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PTA INTRACRANIAL WITH STENT","21000390","CDM","361","RC","61635","HCPCS",,,"facility","outpatient",,,,"21204","21204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DILATATION INTRACRANIAL VASOSPASM INITIAL VESSEL","21000391","CDM","361","RC","61640","HCPCS",,,"facility","inpatient",,,"GY","3439","3439",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG DILATATION INTRACRANIAL VASOSPASM INITIAL VESSEL","21000391","CDM","361","RC","61640","HCPCS",,,"facility","outpatient",,,"GY","3439","3439",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG BLLN DILATE IC VSPSM PRC EA ADD SAME VAS TERR","21000392","CDM","361","RC","61641","HCPCS",,,"facility","inpatient",,,"GY","1037","1037",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG BLLN DILATE IC VSPSM PRC EA ADD SAME VAS TERR","21000392","CDM","361","RC","61641","HCPCS",,,"facility","outpatient",,,"GY","1037","1037",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG BLLN DILATE IC VSPSM PRC EA ADD DIFF VAS TERR","21000393","CDM","361","RC","61642","HCPCS",,,"facility","inpatient",,,"GY","2433","2433",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG BLLN DILATE IC VSPSM PRC EA ADD DIFF VAS TERR","21000393","CDM","361","RC","61642","HCPCS",,,"facility","outpatient",,,"GY","2433","2433",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG ASPIRATION OF SPINAL CORD CYST","21000396","CDM","361","RC","62268","HCPCS",,,"facility","inpatient",,,,"4835","4835",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION OF SPINAL CORD CYST","21000396","CDM","361","RC","62268","HCPCS",,,"facility","outpatient",,,,"4835","4835",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUMBAR PUNCTURE DX","21000397","CDM","361","RC","62270","HCPCS",,,"facility","inpatient",,,,"3056","3056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUMBAR PUNCTURE DX","21000397","CDM","361","RC","62270","HCPCS",,,"facility","outpatient",,,,"3056","3056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUMBAR PUNCTURE FOR CSF DRAINAGE","21000398","CDM","361","RC","62272","HCPCS",,,"facility","inpatient",,,,"4223","4223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUMBAR PUNCTURE FOR CSF DRAINAGE","21000398","CDM","361","RC","62272","HCPCS",,,"facility","outpatient",,,,"4223","4223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION BLOOD PATCH","21000399","CDM","361","RC","62273","HCPCS",,,"facility","inpatient",,,,"3551","3551",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION BLOOD PATCH","21000399","CDM","361","RC","62273","HCPCS",,,"facility","outpatient",,,,"3551","3551",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK CERVICAL, THORACIC","21000400","CDM","361","RC","62281","HCPCS",,,"facility","inpatient",,,,"5530","5530",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK CERVICAL, THORACIC","21000400","CDM","361","RC","62281","HCPCS",,,"facility","outpatient",,,,"5530","5530",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK LUMBAR, SACRAL","21000401","CDM","361","RC","62282","HCPCS",,,"facility","inpatient",,,,"4913","4913",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK LUMBAR, SACRAL","21000401","CDM","361","RC","62282","HCPCS",,,"facility","outpatient",,,,"4913","4913",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ MYELOGRAM/CT LUMBAR","21000402","CDM","361","RC","62284","HCPCS",,,"facility","inpatient",,,,"2971","2971",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ MYELOGRAM/CT LUMBAR","21000402","CDM","361","RC","62284","HCPCS",,,"facility","outpatient",,,,"2971","2971",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION DISKOGRAM LUMBAR","21000404","CDM","361","RC","62290","HCPCS",,,"facility","inpatient",,,,"2201","2201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION DISKOGRAM LUMBAR","21000404","CDM","361","RC","62290","HCPCS",,,"facility","outpatient",,,,"2201","2201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION DISKOGRAM CERVICAL","21000405","CDM","361","RC","62291","HCPCS",,,"facility","inpatient",,,,"3761","3761",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION DISKOGRAM CERVICAL","21000405","CDM","361","RC","62291","HCPCS",,,"facility","outpatient",,,,"3761","3761",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMPLANTATION OR REVISION INTRATHECAL OR EPIDURAL CATH FOR MED ADMIN","21000410","CDM","361","RC","62350","HCPCS",,,"facility","inpatient",,,,"19308","19308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMPLANTATION OR REVISION INTRATHECAL OR EPIDURAL CATH FOR MED ADMIN","21000410","CDM","361","RC","62350","HCPCS",,,"facility","outpatient",,,,"19308","19308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRATHECAL OR EPIDURAL CATHETER REMOVAL","21000411","CDM","361","RC","62355","HCPCS",,,"facility","inpatient",,,,"19234","19234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRATHECAL OR EPIDURAL CATHETER REMOVAL","21000411","CDM","361","RC","62355","HCPCS",,,"facility","outpatient",,,,"19234","19234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL SUBCUTANEOUS PUMP OR RESERVOIR FOR INTRATHECAL OR EPIDURAL INFUSION","21000412","CDM","361","RC","62365","HCPCS",,,"facility","inpatient",,,,"22821","22821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL SUBCUTANEOUS PUMP OR RESERVOIR FOR INTRATHECAL OR EPIDURAL INFUSION","21000412","CDM","361","RC","62365","HCPCS",,,"facility","outpatient",,,,"22821","22821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROSTIMULATOR LEAD INSERTION EPIDURAL","21000415","CDM","361","RC","63650","HCPCS",,,"facility","inpatient",,,,"17127","17127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROSTIMULATOR LEAD INSERTION EPIDURAL","21000415","CDM","361","RC","63650","HCPCS",,,"facility","outpatient",,,,"17127","17127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV AA/STRD GREATER OCCIPITAL","21000419","CDM","361","RC","64405","HCPCS",,,"facility","inpatient",,,,"1644","1644",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV AA/STRD GREATER OCCIPITAL","21000419","CDM","361","RC","64405","HCPCS",,,"facility","outpatient",,,,"1644","1644",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD BRACHIAL PLEX IMG SGL","21000421","CDM","361","RC","64415","HCPCS",,,"facility","inpatient",,,,"6902","6902",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD BRACHIAL PLEX IMG SGL","21000421","CDM","361","RC","64415","HCPCS",,,"facility","outpatient",,,,"6902","6902",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD AGENT AXILLARY NERVE IMG SGL","21000422","CDM","361","RC","64417","HCPCS",,,"facility","inpatient",,,,"4622","4622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD AGENT AXILLARY NERVE IMG SGL","21000422","CDM","361","RC","64417","HCPCS",,,"facility","outpatient",,,,"4622","4622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD NRV INTCOSTL SNGL","21000424","CDM","361","RC","64420","HCPCS",,,"facility","inpatient",,,,"3894","3894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD NRV INTCOSTL SNGL","21000424","CDM","361","RC","64420","HCPCS",,,"facility","outpatient",,,,"3894","3894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD INTERCOSTAL NERVE EA ADDT","21000425","CDM","361","RC","64421","HCPCS",,,"facility","inpatient",,,,"3259","3259",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD INTERCOSTAL NERVE EA ADDT","21000425","CDM","361","RC","64421","HCPCS",,,"facility","outpatient",,,,"3259","3259",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV AA/STRD ILIOINGUINAL","21000426","CDM","361","RC","64425","HCPCS",,,"facility","inpatient",,,,"3023","3023",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV AA/STRD ILIOINGUINAL","21000426","CDM","361","RC","64425","HCPCS",,,"facility","outpatient",,,,"3023","3023",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV AA/STRD SCIATIC IMG SNGL","21000427","CDM","361","RC","64445","HCPCS",,,"facility","inpatient",,,,"3496","3496",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV AA/STRD SCIATIC IMG SNGL","21000427","CDM","361","RC","64445","HCPCS",,,"facility","outpatient",,,,"3496","3496",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD OTHER PERIPH/BRANCH","21000429","CDM","361","RC","64450","HCPCS",,,"facility","inpatient",,,,"2247","2247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD OTHER PERIPH/BRANCH","21000429","CDM","361","RC","64450","HCPCS",,,"facility","outpatient",,,,"2247","2247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES&STRD W/IMG TFRML EDRL CRV/THRC 1 LVL","21000434","CDM","361","RC","64479","HCPCS",,,"facility","inpatient",,,,"4431","4431",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES&STRD W/IMG TFRML EDRL CRV/THRC 1 LVL","21000434","CDM","361","RC","64479","HCPCS",,,"facility","outpatient",,,,"4431","4431",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES&STRD W/IMG TFRML EDRL CRV/THRC EA LV","21000435","CDM","361","RC","64480","HCPCS",,,"facility","inpatient",,,,"2769","2769",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES&STRD W/IMG TFRML EDRL CRV/THRC EA LV","21000435","CDM","361","RC","64480","HCPCS",,,"facility","outpatient",,,,"2769","2769",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL","21000436","CDM","361","RC","64483","HCPCS",,,"facility","inpatient",,,,"4901","4901",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL","21000436","CDM","361","RC","64483","HCPCS",,,"facility","outpatient",,,,"4901","4901",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES&STRD W/IMG TFRML EDRL LMBR/SAC EA LV","21000437","CDM","361","RC","64484","HCPCS",,,"facility","inpatient",,,,"2470","2470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES&STRD W/IMG TFRML EDRL LMBR/SAC EA LV","21000437","CDM","361","RC","64484","HCPCS",,,"facility","outpatient",,,,"2470","2470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK CERVICAL SYMPATHETIC","21000439","CDM","361","RC","64510","HCPCS",,,"facility","inpatient",,,,"5733","5733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK CERVICAL SYMPATHETIC","21000439","CDM","361","RC","64510","HCPCS",,,"facility","outpatient",,,,"5733","5733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK SUPERIOR HYPOGASTRIC PLEXUS","21000440","CDM","361","RC","64517","HCPCS",,,"facility","inpatient",,,,"8068","8068",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK SUPERIOR HYPOGASTRIC PLEXUS","21000440","CDM","361","RC","64517","HCPCS",,,"facility","outpatient",,,,"8068","8068",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK LUMBAR OR THORACIC","21000441","CDM","361","RC","64520","HCPCS",,,"facility","inpatient",,,,"5594","5594",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK LUMBAR OR THORACIC","21000441","CDM","361","RC","64520","HCPCS",,,"facility","outpatient",,,,"5594","5594",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK CELIAC PLEXUS","21000442","CDM","361","RC","64530","HCPCS",,,"facility","inpatient",,,,"4697","4697",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NERVE BLOCK CELIAC PLEXUS","21000442","CDM","361","RC","64530","HCPCS",,,"facility","outpatient",,,,"4697","4697",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTRUCTION NERVE OTHER PERIPHERAL","21000452","CDM","361","RC","64640","HCPCS",,,"facility","inpatient",,,,"5732","5732",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTRUCTION NERVE OTHER PERIPHERAL","21000452","CDM","361","RC","64640","HCPCS",,,"facility","outpatient",,,,"5732","5732",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NEUROLYTIC CELIAC PLEXUS","21000453","CDM","361","RC","64680","HCPCS",,,"facility","inpatient",,,,"4156","4156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION NEUROLYTIC CELIAC PLEXUS","21000453","CDM","361","RC","64680","HCPCS",,,"facility","outpatient",,,,"4156","4156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTRUCTION NERVE SUPERIOR HYPOGASTRIC PLEXUS","21000454","CDM","361","RC","64681","HCPCS",,,"facility","inpatient",,,,"3173","3173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTRUCTION NERVE SUPERIOR HYPOGASTRIC PLEXUS","21000454","CDM","361","RC","64681","HCPCS",,,"facility","outpatient",,,,"3173","3173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRABECULOPLASTY","21000464","CDM","361","RC","65855","HCPCS",,,"facility","inpatient",,,,"3804","3804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRABECULOPLASTY","21000464","CDM","361","RC","65855","HCPCS",,,"facility","outpatient",,,,"3804","3804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRIDOTOMY OR IRIDECTOMY LASER","21000468","CDM","361","RC","66761","HCPCS",,,"facility","inpatient",,,,"3913","3913",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRIDOTOMY OR IRIDECTOMY LASER","21000468","CDM","361","RC","66761","HCPCS",,,"facility","outpatient",,,,"3913","3913",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CATARACT LASER CAPSULOTOMY YAG","21000469","CDM","361","RC","66821","HCPCS",,,"facility","inpatient",,,,"3867","3867",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CATARACT LASER CAPSULOTOMY YAG","21000469","CDM","361","RC","66821","HCPCS",,,"facility","outpatient",,,,"3867","3867",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SACROILIAC JOINT ANESTHESIA OR STEROID","21000495","CDM","361","RC","G0260","HCPCS",,,"facility","inpatient",,,,"5128","5128",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION SACROILIAC JOINT ANESTHESIA OR STEROID","21000495","CDM","361","RC","G0260","HCPCS",,,"facility","outpatient",,,,"5128","5128",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASCULAR CLOSURE DEVICE INSERTION","21000496","CDM","361","RC","G0269","HCPCS",,,"facility","inpatient",,,,"3573","3573",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASCULAR CLOSURE DEVICE INSERTION","21000496","CDM","361","RC","G0269","HCPCS",,,"facility","outpatient",,,,"3573","3573",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ INTERMEDIATE JOINT/BURSA W/O US BIL","21000497","CDM","361","RC","20605","HCPCS",,,"facility","inpatient",,,"50","2712","2712",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DRAIN/INJ INTERMEDIATE JOINT/BURSA W/O US BIL","21000497","CDM","361","RC","20605","HCPCS",,,"facility","outpatient",,,"50","2712","2712",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INCISION LINGUAL FRENUM","21000501","CDM","361","RC","41010","HCPCS",,,"facility","inpatient",,,,"268","268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INCISION LINGUAL FRENUM","21000501","CDM","361","RC","41010","HCPCS",,,"facility","outpatient",,,,"268","268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX OF OVARY(S)","21000502","CDM","361","RC","58900","HCPCS",,,"facility","inpatient",,,,"4213","4213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX OF OVARY(S)","21000502","CDM","361","RC","58900","HCPCS",,,"facility","outpatient",,,,"4213","4213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAINAGE ABSCESS SIMPLE/SINGLE","21000503","CDM","510","RC","10060","HCPCS",,,"facility","inpatient",,,,"1268","1268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAINAGE ABSCESS SIMPLE/SINGLE","21000503","CDM","510","RC","10060","HCPCS",,,"facility","outpatient",,,,"1241","1241",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DISC 2ND MEM CAT LASR BIL","21000504","CDM","361","RC","66821","HCPCS",,,"facility","inpatient",,,"50","5800","5800",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DISC 2ND MEM CAT LASR BIL","21000504","CDM","361","RC","66821","HCPCS",,,"facility","outpatient",,,"50","5800","5800",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BX TEMPORAL ARTERY","21000528","CDM","361","RC","37609","HCPCS",,,"facility","inpatient",,,,"15159","15159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX TEMPORAL ARTERY","21000528","CDM","361","RC","37609","HCPCS",,,"facility","outpatient",,,,"15159","15159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV AA/STRD FEM NRV IMG","21000532","CDM","361","RC","64447","HCPCS",,,"facility","inpatient",,,,"6424","6424",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ NRV AA/STRD FEM NRV IMG","21000532","CDM","361","RC","64447","HCPCS",,,"facility","outpatient",,,,"6424","6424",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D CPLX PSTP WND INF","21000546","CDM","361","RC","10180","HCPCS",,,"facility","inpatient",,,,"11942","11942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D CPLX PSTP WND INF","21000546","CDM","361","RC","10180","HCPCS",,,"facility","outpatient",,,,"11942","11942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLLECT BLOOD FROM PICC","21000547","CDM","361","RC","36592","HCPCS",,,"facility","inpatient",,,,"526","526",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLLECT BLOOD FROM PICC","21000547","CDM","361","RC","36592","HCPCS",,,"facility","outpatient",,,,"526","526",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APHERESIS ADSORP OR FILTRA & REINFUSE","21000566","CDM","940","RC","36516","HCPCS",,,"facility","inpatient",,,,"13958","13958",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APHERESIS ADSORP OR FILTRA & REINFUSE","21000566","CDM","940","RC","36516","HCPCS",,,"facility","outpatient",,,,"13958","13958",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLL BLD VNS ACCS DVC","21000568","CDM","510","RC","36591","HCPCS",,,"facility","inpatient",,,,"447","447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLL BLD VNS ACCS DVC","21000568","CDM","510","RC","36591","HCPCS",,,"facility","outpatient",,,,"447","447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE AGE 3 YRS/>","21000569","CDM","361","RC","36410","HCPCS",,,"facility","inpatient",,,,"73","73",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE AGE 3 YRS/>","21000569","CDM","361","RC","36410","HCPCS",,,"facility","outpatient",,,,"73","73",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRQ RF ABLAT TX PUL TUMOR","21000570","CDM","361","RC","32998","HCPCS",,,"facility","inpatient",,,,"12302","12302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRQ RF ABLAT TX PUL TUMOR","21000570","CDM","361","RC","32998","HCPCS",,,"facility","outpatient",,,,"12302","12302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT IMP DEFIB PULSE GEN ONLY W 1 LEAD","21000571","CDM","361","RC","33240","HCPCS",,,"facility","inpatient",,,,"74612","74612",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT IMP DEFIB PULSE GEN ONLY W 1 LEAD","21000571","CDM","361","RC","33240","HCPCS",,,"facility","outpatient",,,,"74612","74612",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT/RPLC PERM IMP DEFIB W TV LEADS SNGL/DUAL","21000572","CDM","361","RC","33249","HCPCS",,,"facility","inpatient",,,,"89176","89176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT/RPLC PERM IMP DEFIB W TV LEADS SNGL/DUAL","21000572","CDM","361","RC","33249","HCPCS",,,"facility","outpatient",,,,"89176","89176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTO W/ INS URETERAL STENT","21000577","CDM","361","RC","52332","HCPCS",,,"facility","inpatient",,,,"15748","15748",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTO W/ INS URETERAL STENT","21000577","CDM","361","RC","52332","HCPCS",,,"facility","outpatient",,,,"15748","15748",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CON IJ G/COLON TUBE","21000578","CDM","361","RC","49465","HCPCS",,,"facility","inpatient",,,,"1788","1788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CON IJ G/COLON TUBE","21000578","CDM","361","RC","49465","HCPCS",,,"facility","outpatient",,,,"1788","1788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION BONE MARROW W BX","21000579","CDM","361","RC","38222","HCPCS",,,"facility","inpatient",,,,"6285","6285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASPIRATION BONE MARROW W BX","21000579","CDM","361","RC","38222","HCPCS",,,"facility","outpatient",,,,"6285","6285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHANGE EXT NEPHROURETERAL CATH","21000580","CDM","361","RC","50387","HCPCS",,,"facility","inpatient",,,,"7986","7986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHANGE EXT NEPHROURETERAL CATH","21000580","CDM","361","RC","50387","HCPCS",,,"facility","outpatient",,,,"7986","7986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR RETINA  DET PHOTOCOAG","21000597","CDM","361","RC","67105","HCPCS",,,"facility","inpatient",,,,"3945","3945",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR RETINA  DET PHOTOCOAG","21000597","CDM","361","RC","67105","HCPCS",,,"facility","outpatient",,,,"3945","3945",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE CERCLAGE SUTURE","21000603","CDM","361","RC","59871","HCPCS",,,"facility","inpatient",,,,"7239","7239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE CERCLAGE SUTURE","21000603","CDM","361","RC","59871","HCPCS",,,"facility","outpatient",,,,"7239","7239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SCLEROSING SOLUTION INJ HEMORRHOIDS","21000605","CDM","361","RC","46500","HCPCS",,,"facility","inpatient",,,,"7702","7702",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX SOFT TISSUE BACK/FLANK SUPERFICIAL","21000607","CDM","361","RC","21920","HCPCS",,,"facility","inpatient",,,,"566","566",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX SOFT TISSUE BACK/FLANK SUPERFICIAL","21000607","CDM","361","RC","21920","HCPCS",,,"facility","outpatient",,,,"566","566",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TX S WND DEHISC SMPL","21000609","CDM","361","RC","12020","HCPCS",,,"facility","inpatient",,,,"4397","4397",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TX S WND DEHISC SMPL","21000609","CDM","361","RC","12020","HCPCS",,,"facility","outpatient",,,,"4397","4397",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CURETTAGE POSTPARTUM","21000610","CDM","361","RC","59160","HCPCS",,,"facility","inpatient",,,,"4951","4951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CURETTAGE POSTPARTUM","21000610","CDM","361","RC","59160","HCPCS",,,"facility","outpatient",,,,"4951","4951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PVB THORACIC SINGLE SITE","21000611","CDM","361","RC","64461","HCPCS",,,"facility","inpatient",,,,"3517","3517",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PVB THORACIC SINGLE SITE","21000611","CDM","361","RC","64461","HCPCS",,,"facility","outpatient",,,,"3517","3517",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PVB THORACIC 2ND+ SITE","21000612","CDM","361","RC","64462","HCPCS",,,"facility","inpatient",,,,"1753","1753",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PVB THORACIC 2ND+ SITE","21000612","CDM","361","RC","64462","HCPCS",,,"facility","outpatient",,,,"1753","1753",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PVB THORACIC CONT INFUSION","21000613","CDM","361","RC","64463","HCPCS",,,"facility","inpatient",,,,"2173","2173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PVB THORACIC CONT INFUSION","21000613","CDM","361","RC","64463","HCPCS",,,"facility","outpatient",,,,"2173","2173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PROCEDURE RADIOACTIVE TRACER ID SENTINEL NODE WO IMAGE BI","21000616","CDM","361","RC","38792","HCPCS",,,"facility","inpatient",,,"50","5436","5436",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ PROCEDURE RADIOACTIVE TRACER ID SENTINEL NODE WO IMAGE BI","21000616","CDM","361","RC","38792","HCPCS",,,"facility","outpatient",,,"50","5436","5436",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US BI","21000619","CDM","361","RC","20610","HCPCS",,,"facility","inpatient",,,"50","2968","2968",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US BI","21000619","CDM","361","RC","20610","HCPCS",,,"facility","outpatient",,,"50","2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US LT","21000620","CDM","361","RC","20610","HCPCS",,,"facility","inpatient",,,"LT","1979","1979",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US LT","21000620","CDM","361","RC","20610","HCPCS",,,"facility","outpatient",,,"LT","1865","1865",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US RT","21000621","CDM","361","RC","20610","HCPCS",,,"facility","inpatient",,,"RT","1979","1979",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US RT","21000621","CDM","361","RC","20610","HCPCS",,,"facility","outpatient",,,"RT","1865","1865",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG VENOGRAM EXTREMITY INJECTION LT","21000627","CDM","361","RC","36005","HCPCS",,,"facility","inpatient",,,"LT","2984","2984",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG VENOGRAM EXTREMITY INJECTION LT","21000627","CDM","361","RC","36005","HCPCS",,,"facility","outpatient",,,"LT","2984","2984",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG VENOGRAM EXTREMITY INJECTION RT","21000628","CDM","361","RC","36005","HCPCS",,,"facility","inpatient",,,"RT","2984","2984",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG VENOGRAM EXTREMITY INJECTION RT","21000628","CDM","361","RC","36005","HCPCS",,,"facility","outpatient",,,"RT","2984","2984",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG VENOGRAM EXTREMITY INJECTION BI","21000629","CDM","361","RC","36005","HCPCS",,,"facility","inpatient",,,"50","4476","4476",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG VENOGRAM EXTREMITY INJECTION BI","21000629","CDM","361","RC","36005","HCPCS",,,"facility","outpatient",,,"50","4476","4476",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG ECMO/ECLS INS PERIPH CANNULA PERC >=6 YRS","21000632","CDM","361","RC","33952","HCPCS",,,"facility","inpatient",,,,"25697","25697",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS PERIPH CANNULA PERC >=6 YRS","21000632","CDM","361","RC","33952","HCPCS",,,"facility","outpatient",,,,"25697","25697",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM SHOULDER LT","21000634","CDM","361","RC","23350","HCPCS",,,"facility","inpatient",,,"LT","1192","1192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INJECTION ARTHROGRAM SHOULDER LT","21000634","CDM","361","RC","23350","HCPCS",,,"facility","outpatient",,,"LT","1192","1192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INJECTION ARTHROGRAM SHOULDER RT","21000635","CDM","361","RC","23350","HCPCS",,,"facility","inpatient",,,"RT","1192","1192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INJECTION ARTHROGRAM SHOULDER RT","21000635","CDM","361","RC","23350","HCPCS",,,"facility","outpatient",,,"RT","1192","1192",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INTMD RPR S/A/T/EXT 2.5 CM/<","21000637","CDM","361","RC","12031","HCPCS",,,"facility","inpatient",,,,"2377","2377",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTMD RPR S/A/T/EXT 2.5 CM/<","21000637","CDM","361","RC","12031","HCPCS",,,"facility","outpatient",,,,"2377","2377",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER CERVICAL/THORACIC EPID WO IMAGE","21000641","CDM","361","RC","62320","HCPCS",,,"facility","inpatient",,,,"2826","2826",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER CERVICAL/THORACIC EPID WO IMAGE","21000641","CDM","361","RC","62320","HCPCS",,,"facility","outpatient",,,,"2826","2826",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER CERVICAL/THORACIC EPID W IMAGE","21000642","CDM","361","RC","62321","HCPCS",,,"facility","inpatient",,,,"4966","4966",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER CERVICAL/THORACIC EPID W IMAGE","21000642","CDM","361","RC","62321","HCPCS",,,"facility","outpatient",,,,"4966","4966",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER LUMBAR/SACRAL EPID WO IMAGE","21000643","CDM","361","RC","62322","HCPCS",,,"facility","inpatient",,,,"7034","7034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER LUMBAR/SACRAL EPID WO IMAGE","21000643","CDM","361","RC","62322","HCPCS",,,"facility","outpatient",,,,"7034","7034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER LUMBAR/SACRAL EPID W IMAGE","21000644","CDM","361","RC","62323","HCPCS",,,"facility","inpatient",,,,"5452","5452",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER LUMBAR/SACRAL EPID W IMAGE","21000644","CDM","361","RC","62323","HCPCS",,,"facility","outpatient",,,,"5452","5452",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER CERVICAL/THORAC W/CATH EPID WO IMAGE","21000645","CDM","361","RC","62324","HCPCS",,,"facility","inpatient",,,,"2246","2246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER CERVICAL/THORAC W/CATH EPID WO IMAGE","21000645","CDM","361","RC","62324","HCPCS",,,"facility","outpatient",,,,"2246","2246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER CERVICAL/THORAC W/CATH EPID W IMAGE","21000646","CDM","361","RC","62325","HCPCS",,,"facility","inpatient",,,,"5520","5520",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER CERVICAL/THORAC W/CATH EPID W IMAGE","21000646","CDM","361","RC","62325","HCPCS",,,"facility","outpatient",,,,"5520","5520",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER LUMBAR/SACRAL W/CATH EPID WO IMAGE","21000647","CDM","361","RC","62326","HCPCS",,,"facility","inpatient",,,,"4516","4516",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER LUMBAR/SACRAL W/CATH EPID WO IMAGE","21000647","CDM","361","RC","62326","HCPCS",,,"facility","outpatient",,,,"4516","4516",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER LUMBAR/SACRAL W/CATH EPID W IMAGE","21000648","CDM","361","RC","62327","HCPCS",,,"facility","inpatient",,,,"7711","7711",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ INTER LUMBAR/SACRAL W/CATH EPID W IMAGE","21000648","CDM","361","RC","62327","HCPCS",,,"facility","outpatient",,,,"7711","7711",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM HIP BI","21000649","CDM","361","RC","27093","HCPCS",,,"facility","inpatient",,,"50","2142","2142",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION ARTHROGRAM HIP BI","21000649","CDM","361","RC","27093","HCPCS",,,"facility","outpatient",,,"50","2142","2142",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION ARTHROGRAM HIP LT","21000650","CDM","361","RC","27093","HCPCS",,,"facility","inpatient",,,"LT","1428","1428",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INJECTION ARTHROGRAM HIP LT","21000650","CDM","361","RC","27093","HCPCS",,,"facility","outpatient",,,"LT","1428","1428",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INJECTION ARTHROGRAM HIP RT","21000651","CDM","361","RC","27093","HCPCS",,,"facility","inpatient",,,"RT","1428","1428",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INJECTION ARTHROGRAM HIP RT","21000651","CDM","361","RC","27093","HCPCS",,,"facility","outpatient",,,"RT","1428","1428",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INTRO CATH DIALYSIS CIRCUIT","21000652","CDM","361","RC","36901","HCPCS",,,"facility","inpatient",,,,"7462","7462",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRO CATH DIALYSIS CIRCUIT","21000652","CDM","361","RC","36901","HCPCS",,,"facility","outpatient",,,,"7462","7462",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRO CATH DIALYSIS CIRCUIT W/BAL","21000653","CDM","361","RC","36902","HCPCS",,,"facility","inpatient",,,,"25038","25038",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRO CATH DIALYSIS CIRCUIT W/BAL","21000653","CDM","361","RC","36902","HCPCS",,,"facility","outpatient",,,,"25038","25038",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRO CATH DIALYSIS CIRCUIT W/STNT","21000654","CDM","361","RC","36903","HCPCS",,,"facility","inpatient",,,,"37877","37877",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRO CATH DIALYSIS CIRCUIT W/STNT","21000654","CDM","361","RC","36903","HCPCS",,,"facility","outpatient",,,,"37877","37877",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THRMBC/NFS DIALYSIS CIRCUIT","21000655","CDM","361","RC","36904","HCPCS",,,"facility","inpatient",,,,"23814","23814",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THRMBC/NFS DIALYSIS CIRCUIT","21000655","CDM","361","RC","36904","HCPCS",,,"facility","outpatient",,,,"23814","23814",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THRMBC/NFS DIALYSIS CIRCUIT W/BAL","21000656","CDM","361","RC","36905","HCPCS",,,"facility","inpatient",,,,"42724","42724",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THRMBC/NFS DIALYSIS CIRCUIT W/BAL","21000656","CDM","361","RC","36905","HCPCS",,,"facility","outpatient",,,,"42724","42724",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THRMBC/NFS DIALYSIS CIRCUIT W/STNT","21000657","CDM","361","RC","36906","HCPCS",,,"facility","inpatient",,,,"55503","55503",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THRMBC/NFS DIALYSIS CIRCUIT W/STNT","21000657","CDM","361","RC","36906","HCPCS",,,"facility","outpatient",,,,"55503","55503",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BALO ANGIOP CTR DIALYSIS SEG","21000658","CDM","361","RC","36907","HCPCS",,,"facility","inpatient",,,,"12178","12178",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BALO ANGIOP CTR DIALYSIS SEG","21000658","CDM","361","RC","36907","HCPCS",,,"facility","outpatient",,,,"12178","12178",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSLUMINAL BALLOON ANGIOP 1ST ART","21000659","CDM","361","RC","37246","HCPCS",,,"facility","inpatient",,,,"22835","22835",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSLUMINAL BALLOON ANGIOP 1ST ART","21000659","CDM","361","RC","37246","HCPCS",,,"facility","outpatient",,,,"22835","22835",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSLUMINAL BALLOON ANGIOP ADDL ART","21000660","CDM","361","RC","37247","HCPCS",,,"facility","inpatient",,,,"13230","13230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSLUMINAL BALLOON ANGIOP ADDL ART","21000660","CDM","361","RC","37247","HCPCS",,,"facility","outpatient",,,,"13230","13230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSLUMINAL BALLOON ANGIOP 1ST VEIN","21000661","CDM","361","RC","37248","HCPCS",,,"facility","inpatient",,,,"22513","22513",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSLUMINAL BALLOON ANGIOP 1ST VEIN","21000661","CDM","361","RC","37248","HCPCS",,,"facility","outpatient",,,,"22513","22513",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSLUMINAL BALLOON ANGIOP ADDL VEIN","21000662","CDM","361","RC","37249","HCPCS",,,"facility","inpatient",,,,"12910","12910",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSLUMINAL BALLOON ANGIOP ADDL VEIN","21000662","CDM","361","RC","37249","HCPCS",,,"facility","outpatient",,,,"12910","12910",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT PLMT CTR DIALYSIS SEG","21000663","CDM","361","RC","36908","HCPCS",,,"facility","inpatient",,,,"12246","12246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STENT PLMT CTR DIALYSIS SEG","21000663","CDM","361","RC","36908","HCPCS",,,"facility","outpatient",,,,"12246","12246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS CIRCUIT EMBOLJ","21000664","CDM","361","RC","36909","HCPCS",,,"facility","inpatient",,,,"10545","10545",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS CIRCUIT EMBOLJ","21000664","CDM","361","RC","36909","HCPCS",,,"facility","outpatient",,,,"10545","10545",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEPHROSTOMY TUBE REMOVAL WITH FLUORO LT","21000666","CDM","361","RC","50389","HCPCS",,,"facility","inpatient",,,"LT","5609","5609",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NEPHROSTOMY TUBE REMOVAL WITH FLUORO LT","21000666","CDM","361","RC","50389","HCPCS",,,"facility","outpatient",,,"LT","5609","5609",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NEPHROSTOMY TUBE REMOVAL WITH FLUORO RT","21000667","CDM","361","RC","50389","HCPCS",,,"facility","inpatient",,,"RT","5609","5609",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NEPHROSTOMY TUBE REMOVAL WITH FLUORO RT","21000667","CDM","361","RC","50389","HCPCS",,,"facility","outpatient",,,"RT","5609","5609",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NEPHROSTOMY TUBE REMOVAL WITH FLUORO BI","21000668","CDM","361","RC","50389","HCPCS",,,"facility","inpatient",,,"50","8414","8414",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG NEPHROSTOMY TUBE REMOVAL WITH FLUORO BI","21000668","CDM","361","RC","50389","HCPCS",,,"facility","outpatient",,,"50","8414","8414",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG ENDOVENOUS MCHNCHEM 1ST VEIN","21000669","CDM","361","RC","36473","HCPCS",,,"facility","inpatient",,,,"42586","42586",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVENOUS MCHNCHEM 1ST VEIN","21000669","CDM","361","RC","36473","HCPCS",,,"facility","outpatient",,,,"42586","42586",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVENOUS MCHNCHEM ADD-ON","21000670","CDM","361","RC","36474","HCPCS",,,"facility","inpatient",,,,"1252","1252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVENOUS MCHNCHEM ADD-ON","21000670","CDM","361","RC","36474","HCPCS",,,"facility","outpatient",,,,"1252","1252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D HEMATOMA OR ABSCESS LEG OR ANKLE","21000671","CDM","361","RC","27603","HCPCS",,,"facility","inpatient",,,,"6986","6986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D HEMATOMA OR ABSCESS LEG OR ANKLE","21000671","CDM","361","RC","27603","HCPCS",,,"facility","outpatient",,,,"6986","6986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D HEMATOMA OR ABSCESS FOREARM AND/OR WRIST","21000672","CDM","361","RC","25028","HCPCS",,,"facility","inpatient",,,,"3847","3847",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D HEMATOMA OR ABSCESS FOREARM AND/OR WRIST","21000672","CDM","361","RC","25028","HCPCS",,,"facility","outpatient",,,,"3847","3847",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG D&C DIAGNOSTIC OR THERAP NOT OB","21000681","CDM","361","RC","58120","HCPCS",,,"facility","inpatient",,,,"11503","11503",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG D&C DIAGNOSTIC OR THERAP NOT OB","21000681","CDM","361","RC","58120","HCPCS",,,"facility","outpatient",,,,"11503","11503",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TX OF MISSED ABORTION 1ST TRIMESTER","21000682","CDM","361","RC","59820","HCPCS",,,"facility","inpatient",,,,"12528","12528",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TX OF MISSED ABORTION 1ST TRIMESTER","21000682","CDM","361","RC","59820","HCPCS",,,"facility","outpatient",,,,"12528","12528",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG TX INCOMPL ABORTION","21000687","CDM","361","RC","59812","HCPCS",,,"facility","inpatient",,,,"8793","8793",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG TX INCOMPL ABORTION","21000687","CDM","361","RC","59812","HCPCS",,,"facility","outpatient",,,,"8793","8793",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TMVI W/PROSTH VALVE PERC APPRCH INCL TRANS PUNC","21000700","CDM","361","RC","0483T","HCPCS",,,"facility","inpatient",,,,"59740","59740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TMVI W/PROSTH VALVE PERC APPRCH INCL TRANS PUNC","21000700","CDM","361","RC","0483T","HCPCS",,,"facility","outpatient",,,,"59740","59740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLATE PULM TUMOR PERQ CRYBL W/ IMAG GUID","21000701","CDM","361","RC","32994","HCPCS",,,"facility","inpatient",,,,"14712","14712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLATE PULM TUMOR PERQ CRYBL W/ IMAG GUID","21000701","CDM","361","RC","32994","HCPCS",,,"facility","outpatient",,,,"14712","14712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-AO NDGFT","21000702","CDM","361","RC","34701","HCPCS",,,"facility","inpatient",,,,"15690","15690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-AO NDGFT","21000702","CDM","361","RC","34701","HCPCS",,,"facility","outpatient",,,,"15690","15690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-AO NDGFT RPT","21000703","CDM","361","RC","34702","HCPCS",,,"facility","inpatient",,,,"25495","25495",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-AO NDGFT RPT","21000703","CDM","361","RC","34702","HCPCS",,,"facility","outpatient",,,,"25495","25495",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-UNILAC NDGFT","21000704","CDM","361","RC","34703","HCPCS",,,"facility","inpatient",,,,"17857","17857",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-UNILAC NDGFT","21000704","CDM","361","RC","34703","HCPCS",,,"facility","outpatient",,,,"17857","17857",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-UNILAC NDGFT RPT","21000705","CDM","361","RC","34704","HCPCS",,,"facility","inpatient",,,,"34963","34963",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-UNILAC NDGFT RPT","21000705","CDM","361","RC","34704","HCPCS",,,"facility","outpatient",,,,"34963","34963",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVAC RPR A-BIILIAC NDGFT","21000706","CDM","361","RC","34705","HCPCS",,,"facility","inpatient",,,,"17642","17642",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVAC RPR A-BIILIAC NDGFT","21000706","CDM","361","RC","34705","HCPCS",,,"facility","outpatient",,,,"17642","17642",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-BIILIAC RPT","21000707","CDM","361","RC","34706","HCPCS",,,"facility","inpatient",,,,"33117","33117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR A-BIILIAC RPT","21000707","CDM","361","RC","34706","HCPCS",,,"facility","outpatient",,,,"33117","33117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR ILIO-ILIAC NDGFT","21000708","CDM","361","RC","34707","HCPCS",,,"facility","inpatient",,,,"13736","13736",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR ILIO-ILIAC NDGFT","21000708","CDM","361","RC","34707","HCPCS",,,"facility","outpatient",,,,"13736","13736",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR ILIO-ILIAC RPT","21000709","CDM","361","RC","34708","HCPCS",,,"facility","inpatient",,,,"28410","28410",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVASC RPR ILIO-ILIAC RPT","21000709","CDM","361","RC","34708","HCPCS",,,"facility","outpatient",,,,"28410","28410",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT XTN PROSTH EVASC RPR","21000710","CDM","361","RC","34709","HCPCS",,,"facility","inpatient",,,,"9984","9984",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT XTN PROSTH EVASC RPR","21000710","CDM","361","RC","34709","HCPCS",,,"facility","outpatient",,,,"9984","9984",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DLYD PLMT XTN PROSTH 1ST VSL","21000711","CDM","361","RC","34710","HCPCS",,,"facility","inpatient",,,,"31594","31594",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DLYD PLMT XTN PROSTH 1ST VSL","21000711","CDM","361","RC","34710","HCPCS",,,"facility","outpatient",,,,"31594","31594",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DLYD PLMT XTN PROSTH EA ADDL","21000712","CDM","361","RC","34711","HCPCS",,,"facility","inpatient",,,,"36937","36937",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DLYD PLMT XTN PROSTH EA ADDL","21000712","CDM","361","RC","34711","HCPCS",,,"facility","outpatient",,,,"36937","36937",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ ACCESS & CLSR FEM ART","21000716","CDM","361","RC","34713","HCPCS",,,"facility","inpatient",,,,"3648","3648",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ ACCESS & CLSR FEM ART","21000716","CDM","361","RC","34713","HCPCS",,,"facility","outpatient",,,,"3648","3648",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL PERIPH CANNULA PERC <=5 YRS","21000719","CDM","361","RC","33965","HCPCS",,,"facility","inpatient",,,,"3072","3072",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL PERIPH CANNULA PERC <=5 YRS","21000719","CDM","361","RC","33965","HCPCS",,,"facility","outpatient",,,,"3072","3072",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL PERIPH CANNULA PERC >=6 YRS","21000720","CDM","361","RC","33966","HCPCS",,,"facility","inpatient",,,,"3704","3704",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL PERIPH CANNULA PERC >=6 YRS","21000720","CDM","361","RC","33966","HCPCS",,,"facility","outpatient",,,,"3704","3704",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS PERIPH CANNULA OPEN <=5 YRS","21000721","CDM","361","RC","33953","HCPCS",,,"facility","inpatient",,,,"30951","30951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS PERIPH CANNULA OPEN <=5 YRS","21000721","CDM","361","RC","33953","HCPCS",,,"facility","outpatient",,,,"30951","30951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS PERIPH CANNULA OPEN >=6 YRS","21000722","CDM","361","RC","33954","HCPCS",,,"facility","inpatient",,,,"31060","31060",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS PERIPH CANNULA OPEN >=6 YRS","21000722","CDM","361","RC","33954","HCPCS",,,"facility","outpatient",,,,"31060","31060",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS CENTRAL CANNULA <=5 YRS","21000723","CDM","361","RC","33955","HCPCS",,,"facility","inpatient",,,,"54231","54231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS CENTRAL CANNULA <=5 YRS","21000723","CDM","361","RC","33955","HCPCS",,,"facility","outpatient",,,,"54231","54231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS CENTRAL CANNULA >=6 YRS","21000724","CDM","361","RC","33956","HCPCS",,,"facility","inpatient",,,,"57225","57225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INS CENTRAL CANNULA >=6 YRS","21000724","CDM","361","RC","33956","HCPCS",,,"facility","outpatient",,,,"57225","57225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS PERIPH CANNULA PERC <=5 YRS","21000725","CDM","361","RC","33957","HCPCS",,,"facility","inpatient",,,,"12053","12053",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS PERIPH CANNULA PERC <=5 YRS","21000725","CDM","361","RC","33957","HCPCS",,,"facility","outpatient",,,,"12053","12053",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS PERIPH CANNULA PERC >=6 YRS","21000726","CDM","361","RC","33958","HCPCS",,,"facility","inpatient",,,,"11252","11252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS PERIPH CANNULA PERC >=6 YRS","21000726","CDM","361","RC","33958","HCPCS",,,"facility","outpatient",,,,"11252","11252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS PERIPH CANNULA OPEN <=5 YRS","21000727","CDM","361","RC","33959","HCPCS",,,"facility","inpatient",,,,"15297","15297",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS PERIPH CANNULA OPEN <=5 YRS","21000727","CDM","361","RC","33959","HCPCS",,,"facility","outpatient",,,,"15297","15297",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS PERIPH CANNULA OPEN >=6 YRS","21000728","CDM","361","RC","33962","HCPCS",,,"facility","inpatient",,,,"15340","15340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS PERIPH CANNULA OPEN >=6 YRS","21000728","CDM","361","RC","33962","HCPCS",,,"facility","outpatient",,,,"15340","15340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS CENTRAL CANNULA <=5 YRS","21000729","CDM","361","RC","33963","HCPCS",,,"facility","inpatient",,,,"30573","30573",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS CENTRAL CANNULA <=5 YRS","21000729","CDM","361","RC","33963","HCPCS",,,"facility","outpatient",,,,"30573","30573",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS CENTRAL CANNULA >=6 YRS","21000730","CDM","361","RC","33964","HCPCS",,,"facility","inpatient",,,,"32271","32271",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS REPOS CENTRAL CANNULA >=6 YRS","21000730","CDM","361","RC","33964","HCPCS",,,"facility","outpatient",,,,"32271","32271",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL PERIPH CANNULA OPEN <=5 YRS","21000731","CDM","361","RC","33969","HCPCS",,,"facility","inpatient",,,,"4548","4548",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL PERIPH CANNULA OPEN <=5 YRS","21000731","CDM","361","RC","33969","HCPCS",,,"facility","outpatient",,,,"4548","4548",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL PERIPH CANNULA OPEN >=6 YRS","21000732","CDM","361","RC","33984","HCPCS",,,"facility","inpatient",,,,"4452","4452",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL PERIPH CANNULA OPEN >=6 YRS","21000732","CDM","361","RC","33984","HCPCS",,,"facility","outpatient",,,,"4452","4452",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL CENTRAL CANNULA <=5 YRS","21000733","CDM","361","RC","33985","HCPCS",,,"facility","inpatient",,,,"8566","8566",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS RMVL CENTRAL CANNULA <=5 YRS","21000733","CDM","361","RC","33985","HCPCS",,,"facility","outpatient",,,,"8566","8566",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO ECLS RMVL CENTRAL CANNULA >=6 YRS","21000734","CDM","361","RC","33986","HCPCS",,,"facility","inpatient",,,,"8154","8154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO ECLS RMVL CENTRAL CANNULA >=6 YRS","21000734","CDM","361","RC","33986","HCPCS",,,"facility","outpatient",,,,"8154","8154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLEURAL CATHETER EXCHANGE","21000737","CDM","361","RC","32999","HCPCS",,,"facility","inpatient",,,,"2574","2574",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLEURAL CATHETER EXCHANGE","21000737","CDM","361","RC","32999","HCPCS",,,"facility","outpatient",,,,"2574","2574",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVENOUS THERAPY CHEMICAL ADHESIVE 1ST VEIN","21000741","CDM","361","RC","36482","HCPCS",,,"facility","inpatient",,,,"15942","15942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVENOUS THERAPY CHEMICAL ADHESIVE 1ST VEIN","21000741","CDM","361","RC","36482","HCPCS",,,"facility","outpatient",,,,"15942","15942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVENOUS THERAPY CHEMICAL ADHESIVE SUBSQ","21000742","CDM","361","RC","36483","HCPCS",,,"facility","inpatient",,,,"1511","1511",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVENOUS THERAPY CHEMICAL ADHESIVE SUBSQ","21000742","CDM","361","RC","36483","HCPCS",,,"facility","outpatient",,,,"1511","1511",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE US 1ST LESION","21000747","CDM","361","RC","10005","HCPCS",,,"facility","inpatient",,,,"2976","2976",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE US 1ST LESION","21000747","CDM","361","RC","10005","HCPCS",,,"facility","outpatient",,,,"2976","2976",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE US EA ADD LESION","21000748","CDM","361","RC","10006","HCPCS",,,"facility","inpatient",,,,"1798","1798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE US EA ADD LESION","21000748","CDM","361","RC","10006","HCPCS",,,"facility","outpatient",,,,"1798","1798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE FLUORO 1ST LESION","21000749","CDM","361","RC","10007","HCPCS",,,"facility","inpatient",,,,"3579","3579",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE FLUORO 1ST LESION","21000749","CDM","361","RC","10007","HCPCS",,,"facility","outpatient",,,,"3579","3579",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE FLUORO EA ADD LESION","21000750","CDM","361","RC","10008","HCPCS",,,"facility","inpatient",,,,"2422","2422",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE FLUORO EA ADD LESION","21000750","CDM","361","RC","10008","HCPCS",,,"facility","outpatient",,,,"2422","2422",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE CT 1ST LESION","21000751","CDM","361","RC","10009","HCPCS",,,"facility","inpatient",,,,"3623","3623",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE CT 1ST LESION","21000751","CDM","361","RC","10009","HCPCS",,,"facility","outpatient",,,,"3623","3623",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE CT EA ADD LESION","21000752","CDM","361","RC","10010","HCPCS",,,"facility","inpatient",,,,"2330","2330",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA BX WITH IMAGE GUIDANCE CT EA ADD LESION","21000752","CDM","361","RC","10010","HCPCS",,,"facility","outpatient",,,,"2330","2330",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC <5 YR WO PORT WO IMAGE GUIDANCE","21000753","CDM","361","RC","36568","HCPCS",,,"facility","inpatient",,,,"1663","1663",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC <5 YR WO PORT WO IMAGE GUIDANCE","21000753","CDM","361","RC","36568","HCPCS",,,"facility","outpatient",,,,"1663","1663",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC >=5 YR WO PORT WO IMAGE GUIDANCE","21000754","CDM","361","RC","36569","HCPCS",,,"facility","inpatient",,,,"4451","4451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC >=5 YR WO PORT WO IMAGE GUIDANCE","21000754","CDM","361","RC","36569","HCPCS",,,"facility","outpatient",,,,"4451","4451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC <5 YR WO PORT W IMAGE GUIDANCE","21000755","CDM","361","RC","36572","HCPCS",,,"facility","inpatient",,,,"3223","3223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC <5 YR WO PORT W IMAGE GUIDANCE","21000755","CDM","361","RC","36572","HCPCS",,,"facility","outpatient",,,,"3223","3223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC >=5 YR WO PORT W IMAGE GUIDANCE","21000756","CDM","361","RC","36573","HCPCS",,,"facility","inpatient",,,,"4995","4995",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC >=5 YR WO PORT W IMAGE GUIDANCE","21000756","CDM","361","RC","36573","HCPCS",,,"facility","outpatient",,,,"4995","4995",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCH BX SKIN SINGLE LESION","21000759","CDM","361","RC","11104","HCPCS",,,"facility","inpatient",,,,"1223","1223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCH BX SKIN SINGLE LESION","21000759","CDM","361","RC","11104","HCPCS",,,"facility","outpatient",,,,"1019","1019",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCH BX SKIN EA SEPARATE/ADDL LES","21000760","CDM","361","RC","11105","HCPCS",,,"facility","inpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCH BX SKIN EA SEPARATE/ADDL LES","21000760","CDM","361","RC","11105","HCPCS",,,"facility","outpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECT CONTRAST ARTHROGRAM/CT/MRI KNEE","21000763","CDM","361","RC","27369","HCPCS",,,"facility","inpatient",,,,"859","859",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECT CONTRAST ARTHROGRAM/CT/MRI KNEE","21000763","CDM","361","RC","27369","HCPCS",,,"facility","outpatient",,,,"859","859",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT/REPLACE PERM LEADLESS C PM RIGHT VENTR","21000764","CDM","361","RC","33274","HCPCS",,,"facility","inpatient",,,,"64312","64312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT/REPLACE PERM LEADLESS C PM RIGHT VENTR","21000764","CDM","361","RC","33274","HCPCS",,,"facility","outpatient",,,,"64312","64312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMVL PERM LEDLS PM R VENTRICLE W/IMG","21000765","CDM","361","RC","33275","HCPCS",,,"facility","inpatient",,,,"12201","12201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMVL PERM LEDLS PM R VENTRICLE W/IMG","21000765","CDM","361","RC","33275","HCPCS",,,"facility","outpatient",,,,"12201","12201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT/PROGRAM SUBQ CARDIAC RHYTHM MNTR","21000766","CDM","361","RC","33285","HCPCS",,,"facility","inpatient",,,,"23980","23980",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT/PROGRAM SUBQ CARDIAC RHYTHM MNTR","21000766","CDM","361","RC","33285","HCPCS",,,"facility","outpatient",,,,"23980","23980",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE SUBQ CARDIAC RHYTHM MNTR","21000767","CDM","361","RC","33286","HCPCS",,,"facility","inpatient",,,,"5952","5952",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE SUBQ CARDIAC RHYTHM MNTR","21000767","CDM","361","RC","33286","HCPCS",,,"facility","outpatient",,,,"5952","5952",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHANGE G TUBE PERC W/O ENDO/IMAGE W/O REVISION","21000768","CDM","361","RC","43762","HCPCS",,,"facility","inpatient",,,,"1812","1812",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHANGE G TUBE PERC W/O ENDO/IMAGE W/O REVISION","21000768","CDM","361","RC","43762","HCPCS",,,"facility","outpatient",,,,"1812","1812",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHANGE G TUBE PERC W/O ENDO/IMAGE W/REVISION","21000769","CDM","361","RC","43763","HCPCS",,,"facility","inpatient",,,,"1784","1784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHANGE G TUBE PERC W/O ENDO/IMAGE W/REVISION","21000769","CDM","361","RC","43763","HCPCS",,,"facility","outpatient",,,,"1784","1784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERITONEAL INSTILL TPA EXISTING CATH","21000775","CDM","361","RC","49999","HCPCS",,,"facility","inpatient",,,,"700","700",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERITONEAL INSTILL TPA EXISTING CATH","21000775","CDM","361","RC","49999","HCPCS",,,"facility","outpatient",,,,"700","700",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPN AX/SUBCLA ART EXPOS","21000787","CDM","361","RC","34715","HCPCS",,,"facility","inpatient",,,,"7818","7818",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPN AX/SUBCLA ART EXPOS","21000787","CDM","361","RC","34715","HCPCS",,,"facility","outpatient",,,,"7818","7818",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERICARDIOCENTESIS W/IMAGING","21000789","CDM","361","RC","33016","HCPCS",,,"facility","inpatient",,,,"7102","7102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERICARDIOCENTESIS W/IMAGING","21000789","CDM","361","RC","33016","HCPCS",,,"facility","outpatient",,,,"7102","7102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRCRD DRG 6YR+ W/O CGEN CAR","21000790","CDM","361","RC","33017","HCPCS",,,"facility","inpatient",,,,"4516","4516",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRCRD DRG 6YR+ W/O CGEN CAR","21000790","CDM","361","RC","33017","HCPCS",,,"facility","outpatient",,,,"4516","4516",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRCRD DRG 0-5YR OR W/ANOMLY","21000791","CDM","361","RC","33018","HCPCS",,,"facility","inpatient",,,,"5573","5573",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRCRD DRG 0-5YR OR W/ANOMLY","21000791","CDM","361","RC","33018","HCPCS",,,"facility","outpatient",,,,"5573","5573",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ PRCRD DRG INSJ CATH CT","21000792","CDM","361","RC","33019","HCPCS",,,"facility","inpatient",,,,"7927","7927",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ PRCRD DRG INSJ CATH CT","21000792","CDM","361","RC","33019","HCPCS",,,"facility","outpatient",,,,"7927","7927",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ AA/STRD NRV INTCOSTL BIL","21000794","CDM","361","RC","64420","HCPCS",,,"facility","inpatient",,,"50","5841","5841",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ AA/STRD NRV INTCOSTL BIL","21000794","CDM","361","RC","64420","HCPCS",,,"facility","outpatient",,,"50","5841","5841",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DX LMBR SPI PNXR W/FLUOR/CT","21000807","CDM","361","RC","62328","HCPCS",,,"facility","inpatient",,,,"3202","3202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DX LMBR SPI PNXR W/FLUOR/CT","21000807","CDM","361","RC","62328","HCPCS",,,"facility","outpatient",,,,"3202","3202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THER SPI PNXR CSF FLUOR/CT","21000808","CDM","361","RC","62329","HCPCS",,,"facility","inpatient",,,,"4391","4391",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THER SPI PNXR CSF FLUOR/CT","21000808","CDM","361","RC","62329","HCPCS",,,"facility","outpatient",,,,"4391","4391",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAT POD BIOPSY","21000809","CDM","361","RC","17999","HCPCS",,,"facility","inpatient",,,,"2970","2970",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAT POD BIOPSY","21000809","CDM","361","RC","17999","HCPCS",,,"facility","outpatient",,,,"2970","2970",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPN AX/SUBCLA ART EXPOS CNDT","21000810","CDM","361","RC","34716","HCPCS",,,"facility","inpatient",,,,"10744","10744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPN AX/SUBCLA ART EXPOS CNDT","21000810","CDM","361","RC","34716","HCPCS",,,"facility","outpatient",,,,"10744","10744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCT ASP HYDROCELE TUNICA VAGINALIS","21000811","CDM","361","RC","55000","HCPCS",,,"facility","inpatient",,,,"6302","6302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCT ASP HYDROCELE TUNICA VAGINALIS","21000811","CDM","361","RC","55000","HCPCS",,,"facility","outpatient",,,,"6302","6302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLT IRE 1+ O/T LV/PRST8 PRQ","21000814","CDM","361","RC","0600T","HCPCS",,,"facility","inpatient",,,,"18597","18597",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABLT IRE 1+ O/T LV/PRST8 PRQ","21000814","CDM","361","RC","0600T","HCPCS",,,"facility","outpatient",,,,"18597","18597",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVASC INTRAVCASC LITHOTRIPSY","21000816","CDM","361","RC","C9764","HCPCS",,,"facility","inpatient",,,,"27307","27307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVASC INTRAVCASC LITHOTRIPSY","21000816","CDM","361","RC","C9764","HCPCS",,,"facility","outpatient",,,,"27307","27307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVASC INTRA LITHOTRIP STENT","21000817","CDM","361","RC","C9765","HCPCS",,,"facility","inpatient",,,,"44006","44006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVASC INTRA LITHOTRIP STENT","21000817","CDM","361","RC","C9765","HCPCS",,,"facility","outpatient",,,,"44006","44006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVASC INTRA LITHOTRIP ATHERECTOMY","21000818","CDM","361","RC","C9766","HCPCS",,,"facility","inpatient",,,,"37710","37710",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVASC INTRA LITHOTRIP ATHERECTOMY","21000818","CDM","361","RC","C9766","HCPCS",,,"facility","outpatient",,,,"37710","37710",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG LT","21000822","CDM","361","RC","32408","HCPCS",,,"facility","inpatient",,,"LT","5511","5511",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG LT","21000822","CDM","361","RC","32408","HCPCS",,,"facility","outpatient",,,"LT","5511","5511",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG RT","21000823","CDM","361","RC","32408","HCPCS",,,"facility","inpatient",,,"RT","5511","5511",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG RT","21000823","CDM","361","RC","32408","HCPCS",,,"facility","outpatient",,,"RT","5511","5511",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REVASC LITHOTRIP TIBI/PERONE","21000824","CDM","361","RC","C9772","HCPCS",,,"facility","inpatient",,,,"31943","31943",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVASC LITHOTRIP TIBI/PERONE","21000824","CDM","361","RC","C9772","HCPCS",,,"facility","outpatient",,,,"31943","31943",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML ANGP NT/RECR COA","21000838","CDM","361","RC","33897","HCPCS",,,"facility","inpatient",,,,"20853","20853",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML ANGP NT/RECR COA","21000838","CDM","361","RC","33897","HCPCS",,,"facility","outpatient",,,,"20853","20853",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION ARTHROGRAM ELBOW BI","21000853","CDM","361","RC","24220","HCPCS",,,"facility","inpatient",,,"50","5078","5078",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION ARTHROGRAM ELBOW BI","21000853","CDM","361","RC","24220","HCPCS",,,"facility","outpatient",,,"50","5078","5078",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION ARTHROGRAM WRIST BI","21000854","CDM","361","RC","25246","HCPCS",,,"facility","inpatient",,,"50","1221","1221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION ARTHROGRAM WRIST BI","21000854","CDM","361","RC","25246","HCPCS",,,"facility","outpatient",,,"50","1221","1221",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION ARTHROGRAM ANKLE BI","21000855","CDM","361","RC","27648","HCPCS",,,"facility","inpatient",,,"50","5902","5902",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION ARTHROGRAM ANKLE BI","21000855","CDM","361","RC","27648","HCPCS",,,"facility","outpatient",,,"50","5902","5902",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY RENAL BI","21000856","CDM","361","RC","50200","HCPCS",,,"facility","inpatient",,,"50","6534","6534",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY RENAL BI","21000856","CDM","361","RC","50200","HCPCS",,,"facility","outpatient",,,"50","6534","6534",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION FOR DUCTOGRAM OR GALACTOGRAM BI","21000857","CDM","361","RC","19030","HCPCS",,,"facility","inpatient",,,"50","1827","1827",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJECTION FOR DUCTOGRAM OR GALACTOGRAM BI","21000857","CDM","361","RC","19030","HCPCS",,,"facility","outpatient",,,"50","1827","1827",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY LYMPH NODE SUPERFICIAL BI","21000858","CDM","361","RC","38505","HCPCS",,,"facility","inpatient",,,"50","6654","6654",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY LYMPH NODE SUPERFICIAL BI","21000858","CDM","361","RC","38505","HCPCS",,,"facility","outpatient",,,"50","6654","6654",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TRACHEOSTOMY PLANNED SEPARATE PROCEDURE","21000860","CDM","361","RC","31600","HCPCS",,,"facility","inpatient",,,,"9513","9513",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRACHEOSTOMY PLANNED SEPARATE PROCEDURE","21000860","CDM","361","RC","31600","HCPCS",,,"facility","outpatient",,,,"9513","9513",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ANGIOP UNI SF LES 1ST VSL","21000899","CDM","361","RC","37254","HCPCS",,,"facility","inpatient",,,,"38890","38890",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ANGIOP UNI SF LES 1ST VSL","21000899","CDM","361","RC","37254","HCPCS",,,"facility","outpatient",,,,"38890","38890",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ANGIOP UNI CPLX LES 1ST VSL","21000900","CDM","361","RC","37256","HCPCS",,,"facility","inpatient",,,,"54446","54446",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ANGIOP UNI CPLX LES 1ST VSL","21000900","CDM","361","RC","37256","HCPCS",,,"facility","outpatient",,,,"54446","54446",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ST PLMT UNI SF LES 1ST VSL","21000901","CDM","361","RC","37258","HCPCS",,,"facility","inpatient",,,,"56644","56644",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ST PLMT UNI SF LES 1ST VSL","21000901","CDM","361","RC","37258","HCPCS",,,"facility","outpatient",,,,"56644","56644",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ST PLMT UNI CPLX LES 1ST VSL","21000902","CDM","361","RC","37260","HCPCS",,,"facility","inpatient",,,,"79302","79302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ST PLMT UNI CPLX LES 1ST VSL","21000902","CDM","361","RC","37260","HCPCS",,,"facility","outpatient",,,,"79302","79302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ANGIOP UNI SF LES EA ADDL VSL","21000903","CDM","361","RC","37255","HCPCS",,,"facility","inpatient",,,,"18638","18638",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ANGIOP UNI SF LES EA ADDL VSL","21000903","CDM","361","RC","37255","HCPCS",,,"facility","outpatient",,,,"18638","18638",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ANGIOP UNI CPLX LES EA ADDL VSL","21000904","CDM","361","RC","37257","HCPCS",,,"facility","inpatient",,,,"26093","26093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ANGIOP UNI CPLX LES EA ADDL VSL","21000904","CDM","361","RC","37257","HCPCS",,,"facility","outpatient",,,,"26093","26093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ST PLMT UNI SF LES EA ADDL VSL","21000905","CDM","361","RC","37259","HCPCS",,,"facility","inpatient",,,,"20947","20947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ST PLMT UNI SF LES EA ADDL VSL","21000905","CDM","361","RC","37259","HCPCS",,,"facility","outpatient",,,,"20947","20947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ST PLMT UNI CPLX LES EA ADD VSL","21000906","CDM","361","RC","37261","HCPCS",,,"facility","inpatient",,,,"29326","29326",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC IVT ST PLMT UNI CPLX LES EA ADD VSL","21000906","CDM","361","RC","37261","HCPCS",,,"facility","outpatient",,,,"29326","29326",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ANGIOP UNI SF LES 1ST VSL","21000907","CDM","361","RC","37263","HCPCS",,,"facility","inpatient",,,,"26364","26364",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ANGIOP UNI SF LES 1ST VSL","21000907","CDM","361","RC","37263","HCPCS",,,"facility","outpatient",,,,"26364","26364",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ANGIOP UNI CPLX LES 1ST VSL","21000908","CDM","361","RC","37265","HCPCS",,,"facility","inpatient",,,,"36909","36909",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ANGIOP UNI CPLX LES 1ST VSL","21000908","CDM","361","RC","37265","HCPCS",,,"facility","outpatient",,,,"36909","36909",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ATHRC UNI SF LES 1ST VSL","21000909","CDM","361","RC","37271","HCPCS",,,"facility","inpatient",,,,"38359","38359",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ATHRC UNI SF LES 1ST VSL","21000909","CDM","361","RC","37271","HCPCS",,,"facility","outpatient",,,,"38359","38359",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ATHRC UNI CPLX LES 1ST VSL","21000910","CDM","361","RC","37273","HCPCS",,,"facility","inpatient",,,,"53703","53703",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ATHRC UNI CPLX LES 1ST VSL","21000910","CDM","361","RC","37273","HCPCS",,,"facility","outpatient",,,,"53703","53703",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ST PLMT UNI SF LES 1ST VSL","21000911","CDM","361","RC","37267","HCPCS",,,"facility","inpatient",,,,"39799","39799",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ST PLMT UNI SF LES 1ST VSL","21000911","CDM","361","RC","37267","HCPCS",,,"facility","outpatient",,,,"39799","39799",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ST PLMT UNI CPLX LES 1ST VSL","21000912","CDM","361","RC","37269","HCPCS",,,"facility","inpatient",,,,"55719","55719",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ST PLMT UNI CPLX LES 1ST VSL","21000912","CDM","361","RC","37269","HCPCS",,,"facility","outpatient",,,,"55719","55719",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ST ATHRC UNI SF LES 1ST VSL","21000913","CDM","361","RC","37275","HCPCS",,,"facility","inpatient",,,,"53409","53409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ST ATHRC UNI SF LES 1ST VSL","21000913","CDM","361","RC","37275","HCPCS",,,"facility","outpatient",,,,"53409","53409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ST ATHRC UNI CPLX LES 1ST VSL","21000914","CDM","361","RC","37277","HCPCS",,,"facility","inpatient",,,,"74772","74772",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC FPVT ST ATHRC UNI CPLX LES 1ST VSL","21000914","CDM","361","RC","37277","HCPCS",,,"facility","outpatient",,,,"74772","74772",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ANGIOP UNI SF LES 1ST VSL","21000915","CDM","361","RC","37280","HCPCS",,,"facility","inpatient",,,,"27954","27954",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ANGIOP UNI SF LES 1ST VSL","21000915","CDM","361","RC","37280","HCPCS",,,"facility","outpatient",,,,"27954","27954",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ANGIOP UNI CPLX LES 1ST VSL","21000916","CDM","361","RC","37282","HCPCS",,,"facility","inpatient",,,,"39136","39136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ANGIOP UNI CPLX LES 1ST VSL","21000916","CDM","361","RC","37282","HCPCS",,,"facility","outpatient",,,,"39136","39136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ATHRC UNI SF LES 1ST VSL","21000917","CDM","361","RC","37288","HCPCS",,,"facility","inpatient",,,,"47353","47353",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ATHRC UNI SF LES 1ST VSL","21000917","CDM","361","RC","37288","HCPCS",,,"facility","outpatient",,,,"47353","47353",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ATHRC UNI CPLX LES 1ST VSL","21000918","CDM","361","RC","37290","HCPCS",,,"facility","inpatient",,,,"66295","66295",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ATHRC UNI CPLX LES 1ST VSL","21000918","CDM","361","RC","37290","HCPCS",,,"facility","outpatient",,,,"66295","66295",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST PLMT UNI SF LES 1ST VSL","21000919","CDM","361","RC","37284","HCPCS",,,"facility","inpatient",,,,"43291","43291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST PLMT UNI SF LES 1ST VSL","21000919","CDM","361","RC","37284","HCPCS",,,"facility","outpatient",,,,"43291","43291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST PLMT UNI CPLX LES 1ST VSL","21000920","CDM","361","RC","37286","HCPCS",,,"facility","inpatient",,,,"60607","60607",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST PLMT UNI CPLX LES 1ST VSL","21000920","CDM","361","RC","37286","HCPCS",,,"facility","outpatient",,,,"60607","60607",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST ATHRC UNI SF LES 1ST VSL","21000921","CDM","361","RC","37292","HCPCS",,,"facility","inpatient",,,,"58196","58196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST ATHRC UNI SF LES 1ST VSL","21000921","CDM","361","RC","37292","HCPCS",,,"facility","outpatient",,,,"58196","58196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST ATHRC UNI CPLX LES 1ST VSL","21000922","CDM","361","RC","37294","HCPCS",,,"facility","inpatient",,,,"81474","81474",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST ATHRC UNI CPLX LES 1ST VSL","21000922","CDM","361","RC","37294","HCPCS",,,"facility","outpatient",,,,"81474","81474",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ANGIOP UNI SF LES EA ADDL VSL","21000923","CDM","361","RC","37281","HCPCS",,,"facility","inpatient",,,,"16066","16066",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ANGIOP UNI SF LES EA ADDL VSL","21000923","CDM","361","RC","37281","HCPCS",,,"facility","outpatient",,,,"16066","16066",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ANGIOP UNI CPLX LES EA ADD VSL","21000924","CDM","361","RC","37283","HCPCS",,,"facility","inpatient",,,,"22492","22492",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ANGIOP UNI CPLX LES EA ADD VSL","21000924","CDM","361","RC","37283","HCPCS",,,"facility","outpatient",,,,"22492","22492",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ATHRC UNI SF LES EA ADDL VSL","21000925","CDM","361","RC","37289","HCPCS",,,"facility","inpatient",,,,"23075","23075",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ATHRC UNI SF LES EA ADDL VSL","21000925","CDM","361","RC","37289","HCPCS",,,"facility","outpatient",,,,"23075","23075",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ATHRC UNI CPLX LES EA ADDL VSL","21000926","CDM","361","RC","37291","HCPCS",,,"facility","inpatient",,,,"32306","32306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ATHRC UNI CPLX LES EA ADDL VSL","21000926","CDM","361","RC","37291","HCPCS",,,"facility","outpatient",,,,"32306","32306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST PLMT UNI SF LES EA ADDL VSL","21000927","CDM","361","RC","37285","HCPCS",,,"facility","inpatient",,,,"30251","30251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVASC TPVT ST PLMT UNI SF LES EA ADDL VSL","21000927","CDM","361","RC","37285","HCPCS",,,"facility","outpatient",,,,"30251","30251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVSC TPVT ST PLMT UNI CPLX LES EA ADD VSL","21000928","CDM","361","RC","37287","HCPCS",,,"facility","inpatient",,,,"42352","42352",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVSC TPVT ST PLMT UNI CPLX LES EA ADD VSL","21000928","CDM","361","RC","37287","HCPCS",,,"facility","outpatient",,,,"42352","42352",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVSC FPVT ST PLMT UNI CPLX LES EA ADD VSL","21000934","CDM","361","RC","37270","HCPCS",,,"facility","inpatient",,,,"31147","31147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REVSC EVSC FPVT ST PLMT UNI CPLX LES EA ADD VSL","21000934","CDM","361","RC","37270","HCPCS",,,"facility","outpatient",,,,"31147","31147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DCMPRN FASCT LEG ANT&/LAT&PST CMPRT","21000944","CDM","361","RC","27602","HCPCS",,,"facility","inpatient",,,,"17175","17175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DCMPRN FASCT LEG ANT&/LAT&PST CMPRT","21000944","CDM","361","RC","27602","HCPCS",,,"facility","outpatient",,,,"17175","17175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DEXA BODY COMPOSITION","30000000","CDM","320","RC","76499","HCPCS",,,"facility","inpatient",,,,"443","443",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DEXA BODY COMPOSITION","30000000","CDM","320","RC","76499","HCPCS",,,"facility","outpatient",,,,"443","443",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR EYE FOR FB","30000002","CDM","320","RC","70030","HCPCS",,,"facility","inpatient",,,,"609","609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR EYE FOR FB","30000002","CDM","320","RC","70030","HCPCS",,,"facility","outpatient",,,,"609","609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MANDIBLE LESS 4 VIEW","30000003","CDM","320","RC","70100","HCPCS",,,"facility","inpatient",,,,"585","585",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MANDIBLE LESS 4 VIEW","30000003","CDM","320","RC","70100","HCPCS",,,"facility","outpatient",,,,"585","585",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MANDIBLE 4 VIEW OR MORE","30000004","CDM","320","RC","70110","HCPCS",,,"facility","inpatient",,,,"938","938",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MANDIBLE 4 VIEW OR MORE","30000004","CDM","320","RC","70110","HCPCS",,,"facility","outpatient",,,,"938","938",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MASTOIDS LESS 3 VIEW","30000005","CDM","320","RC","70120","HCPCS",,,"facility","inpatient",,,,"828","828",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MASTOIDS LESS 3 VIEW","30000005","CDM","320","RC","70120","HCPCS",,,"facility","outpatient",,,,"828","828",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MASTOIDS 3 VIEW OR MORE","30000006","CDM","320","RC","70130","HCPCS",,,"facility","inpatient",,,,"1021","1021",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MASTOIDS 3 VIEW OR MORE","30000006","CDM","320","RC","70130","HCPCS",,,"facility","outpatient",,,,"1021","1021",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FACIAL BONE LESS 3 VIEW","30000007","CDM","320","RC","70140","HCPCS",,,"facility","inpatient",,,,"764","764",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FACIAL BONE LESS 3 VIEW","30000007","CDM","320","RC","70140","HCPCS",,,"facility","outpatient",,,,"764","764",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FACIAL BONE 3 VIEW OR MORE","30000008","CDM","320","RC","70150","HCPCS",,,"facility","inpatient",,,,"915","915",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FACIAL BONE 3 VIEW OR MORE","30000008","CDM","320","RC","70150","HCPCS",,,"facility","outpatient",,,,"915","915",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR NASAL BONES 3 VIEW OR MORE","30000009","CDM","320","RC","70160","HCPCS",,,"facility","inpatient",,,,"869","869",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR NASAL BONES 3 VIEW OR MORE","30000009","CDM","320","RC","70160","HCPCS",,,"facility","outpatient",,,,"869","869",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR OPTIC FORAMINA","30000010","CDM","320","RC","70190","HCPCS",,,"facility","inpatient",,,,"437","437",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR OPTIC FORAMINA","30000010","CDM","320","RC","70190","HCPCS",,,"facility","outpatient",,,,"437","437",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ORBITS 4 VIEW OR MORE","30000011","CDM","320","RC","70200","HCPCS",,,"facility","inpatient",,,,"757","757",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ORBITS 4 VIEW OR MORE","30000011","CDM","320","RC","70200","HCPCS",,,"facility","outpatient",,,,"757","757",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SINUS PARA LESS 3 VIEW","30000012","CDM","320","RC","70210","HCPCS",,,"facility","inpatient",,,,"607","607",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SINUS PARA LESS 3 VIEW","30000012","CDM","320","RC","70210","HCPCS",,,"facility","outpatient",,,,"607","607",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SINUS PARA 3 VIEW OR MORE","30000013","CDM","320","RC","70220","HCPCS",,,"facility","inpatient",,,,"740","740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SINUS PARA 3 VIEW OR MORE","30000013","CDM","320","RC","70220","HCPCS",,,"facility","outpatient",,,,"740","740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SELLA TURCICA","30000014","CDM","320","RC","70240","HCPCS",,,"facility","inpatient",,,,"815","815",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SELLA TURCICA","30000014","CDM","320","RC","70240","HCPCS",,,"facility","outpatient",,,,"815","815",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SKULL LESS 4 VIEW","30000015","CDM","320","RC","70250","HCPCS",,,"facility","inpatient",,,,"967","967",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SKULL LESS 4 VIEW","30000015","CDM","320","RC","70250","HCPCS",,,"facility","outpatient",,,,"967","967",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SKULL 4 VIEW OR MORE","30000016","CDM","320","RC","70260","HCPCS",,,"facility","inpatient",,,,"1071","1071",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SKULL 4 VIEW OR MORE","30000016","CDM","320","RC","70260","HCPCS",,,"facility","outpatient",,,,"1071","1071",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DENTAL FULL EX","30000017","CDM","320","RC","70320","HCPCS",,,"facility","inpatient",,,,"1456","1456",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DENTAL FULL EX","30000017","CDM","320","RC","70320","HCPCS",,,"facility","outpatient",,,,"1456","1456",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TMJ BILAT","30000019","CDM","320","RC","70330","HCPCS",,,"facility","inpatient",,,,"704","704",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TMJ BILAT","30000019","CDM","320","RC","70330","HCPCS",,,"facility","outpatient",,,,"704","704",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ARTHRO TMJ","30000020","CDM","322","RC","70332","HCPCS",,,"facility","inpatient",,,,"1793","1793",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ARTHRO TMJ","30000020","CDM","322","RC","70332","HCPCS",,,"facility","outpatient",,,,"1793","1793",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ORTHOPANTOG","30000022","CDM","320","RC","70355","HCPCS",,,"facility","inpatient",,,,"459","459",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ORTHOPANTOG","30000022","CDM","320","RC","70355","HCPCS",,,"facility","outpatient",,,,"459","459",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR NECK SOFT TISSUE","30000023","CDM","320","RC","70360","HCPCS",,,"facility","inpatient",,,,"744","744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR NECK SOFT TISSUE","30000023","CDM","320","RC","70360","HCPCS",,,"facility","outpatient",,,,"744","744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHARYNGEAL SPEECH EVAL W CINE/VIDEO","30000025","CDM","320","RC","70371","HCPCS",,,"facility","inpatient",,,,"1932","1932",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHARYNGEAL SPEECH EVAL W CINE/VIDEO","30000025","CDM","320","RC","70371","HCPCS",,,"facility","outpatient",,,,"1932","1932",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SALIVARY GLAND CALC","30000027","CDM","320","RC","70380","HCPCS",,,"facility","inpatient",,,,"936","936",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SALIVARY GLAND CALC","30000027","CDM","320","RC","70380","HCPCS",,,"facility","outpatient",,,,"936","936",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SIALOG","30000028","CDM","320","RC","70390","HCPCS",,,"facility","inpatient",,,,"2952","2952",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SIALOG","30000028","CDM","320","RC","70390","HCPCS",,,"facility","outpatient",,,,"2952","2952",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR RIBS BILAT 3 VIEW","30000041","CDM","320","RC","71110","HCPCS",,,"facility","inpatient",,,,"1049","1049",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR RIBS BILAT 3 VIEW","30000041","CDM","320","RC","71110","HCPCS",,,"facility","outpatient",,,,"1049","1049",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR RIBS BILAT W PA CXR","30000042","CDM","320","RC","71111","HCPCS",,,"facility","inpatient",,,,"1276","1276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR RIBS BILAT W PA CXR","30000042","CDM","320","RC","71111","HCPCS",,,"facility","outpatient",,,,"1276","1276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR STERNUM 2 VIEW OR MORE","30000043","CDM","320","RC","71120","HCPCS",,,"facility","inpatient",,,,"728","728",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR STERNUM 2 VIEW OR MORE","30000043","CDM","320","RC","71120","HCPCS",,,"facility","outpatient",,,,"728","728",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR STERNOCLAVIC 3 VIEW MORE","30000044","CDM","320","RC","71130","HCPCS",,,"facility","inpatient",,,,"589","589",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR STERNOCLAVIC 3 VIEW MORE","30000044","CDM","320","RC","71130","HCPCS",,,"facility","outpatient",,,,"589","589",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IJ SI JNT ANES/ST W/GD BILAT","30000047","CDM","361","RC","G0260","HCPCS",,,"facility","inpatient",,,"50","7692","7692",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG IJ SI JNT ANES/ST W/GD BILAT","30000047","CDM","361","RC","G0260","HCPCS",,,"facility","outpatient",,,"50","7692","7692",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR SPINE CERVICAL 2-3 VIEWS","30000049","CDM","320","RC","72040","HCPCS",,,"facility","inpatient",,,,"864","864",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE CERVICAL 2-3 VIEWS","30000049","CDM","320","RC","72040","HCPCS",,,"facility","outpatient",,,,"864","864",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE CERVICAL 4 OR 5 VIEWS","30000050","CDM","320","RC","72050","HCPCS",,,"facility","inpatient",,,,"1175","1175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE CERVICAL 4 OR 5 VIEWS","30000050","CDM","320","RC","72050","HCPCS",,,"facility","outpatient",,,,"1175","1175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE CERVICAL 6 OR MORE VIEWS","30000051","CDM","320","RC","72052","HCPCS",,,"facility","inpatient",,,,"1308","1308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE CERVICAL 6 OR MORE VIEWS","30000051","CDM","320","RC","72052","HCPCS",,,"facility","outpatient",,,,"1308","1308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE THOR 2 VIEW","30000053","CDM","320","RC","72070","HCPCS",,,"facility","inpatient",,,,"932","932",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE THOR 2 VIEW","30000053","CDM","320","RC","72070","HCPCS",,,"facility","outpatient",,,,"932","932",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE THOR 3 VIEW","30000054","CDM","320","RC","72072","HCPCS",,,"facility","inpatient",,,,"980","980",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE THOR 3 VIEW","30000054","CDM","320","RC","72072","HCPCS",,,"facility","outpatient",,,,"980","980",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE THOR 4 VIEW OR MORE","30000055","CDM","320","RC","72074","HCPCS",,,"facility","inpatient",,,,"912","912",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE THOR 4 VIEW OR MORE","30000055","CDM","320","RC","72074","HCPCS",,,"facility","outpatient",,,,"912","912",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE THORACOLUMBAR JNCTN 2 VIEW","30000056","CDM","320","RC","72080","HCPCS",,,"facility","inpatient",,,,"805","805",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE THORACOLUMBAR JNCTN 2 VIEW","30000056","CDM","320","RC","72080","HCPCS",,,"facility","outpatient",,,,"805","805",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE LUMB 2 OR 3 VIEW","30000058","CDM","320","RC","72100","HCPCS",,,"facility","inpatient",,,,"966","966",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE LUMB 2 OR 3 VIEW","30000058","CDM","320","RC","72100","HCPCS",,,"facility","outpatient",,,,"966","966",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE LUMB 4 VIEW OR MORE","30000059","CDM","320","RC","72110","HCPCS",,,"facility","inpatient",,,,"1151","1151",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE LUMB 4 VIEW OR MORE","30000059","CDM","320","RC","72110","HCPCS",,,"facility","outpatient",,,,"1151","1151",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE L/S COMPLETE W BENDING VWS MIN 6 VWS","30000060","CDM","320","RC","72114","HCPCS",,,"facility","inpatient",,,,"1169","1169",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE L/S COMPLETE W BENDING VWS MIN 6 VWS","30000060","CDM","320","RC","72114","HCPCS",,,"facility","outpatient",,,,"1169","1169",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE LUMB 4 BENDING VIEW","30000061","CDM","320","RC","72120","HCPCS",,,"facility","inpatient",,,,"836","836",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE LUMB 4 BENDING VIEW","30000061","CDM","320","RC","72120","HCPCS",,,"facility","outpatient",,,,"836","836",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PELVIC 1 OR 2 VIEW","30000062","CDM","320","RC","72170","HCPCS",,,"facility","inpatient",,,,"770","770",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PELVIC 1 OR 2 VIEW","30000062","CDM","320","RC","72170","HCPCS",,,"facility","outpatient",,,,"770","770",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PELVIC 3 VIEW OR MORE","30000063","CDM","320","RC","72190","HCPCS",,,"facility","inpatient",,,,"890","890",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PELVIC 3 VIEW OR MORE","30000063","CDM","320","RC","72190","HCPCS",,,"facility","outpatient",,,,"890","890",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SI JOINT 1 OR 2 VIEW","30000064","CDM","320","RC","72200","HCPCS",,,"facility","inpatient",,,,"571","571",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SI JOINT 1 OR 2 VIEW","30000064","CDM","320","RC","72200","HCPCS",,,"facility","outpatient",,,,"571","571",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SI JOINT 3 VIEW OR MORE","30000065","CDM","320","RC","72202","HCPCS",,,"facility","inpatient",,,,"816","816",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SI JOINT 3 VIEW OR MORE","30000065","CDM","320","RC","72202","HCPCS",,,"facility","outpatient",,,,"816","816",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SACRUM COCCYX","30000066","CDM","320","RC","72220","HCPCS",,,"facility","inpatient",,,,"928","928",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SACRUM COCCYX","30000066","CDM","320","RC","72220","HCPCS",,,"facility","outpatient",,,,"928","928",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MYELOGRAM THOR","30000068","CDM","320","RC","72255","HCPCS",,,"facility","inpatient",,,,"3075","3075",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MYELOGRAM THOR","30000068","CDM","320","RC","72255","HCPCS",,,"facility","outpatient",,,,"3075","3075",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEVICE BREAST 1ST MAMMO GUIDE","30000071","CDM","361","RC","19281","HCPCS",,,"facility","inpatient",,,,"3001","3001",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEVICE BREAST 1ST MAMMO GUIDE","30000071","CDM","361","RC","19281","HCPCS",,,"facility","outpatient",,,,"3001","3001",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEVICE BREAST ADD MAMMO GUIDE","30000073","CDM","361","RC","19282","HCPCS",,,"facility","inpatient",,,,"1378","1378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEVICE BREAST ADD MAMMO GUIDE","30000073","CDM","361","RC","19282","HCPCS",,,"facility","outpatient",,,,"1378","1378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CLAVICLE BILATERAL","30000075","CDM","320","RC","73000","HCPCS",,,"facility","inpatient",,,"50","1154","1154",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR CLAVICLE BILATERAL","30000075","CDM","320","RC","73000","HCPCS",,,"facility","outpatient",,,"50","1154","1154",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR CLAVICLE LT","30000076","CDM","320","RC","73000","HCPCS",,,"facility","inpatient",,,"LT","769","769",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR CLAVICLE LT","30000076","CDM","320","RC","73000","HCPCS",,,"facility","outpatient",,,"LT","769","769",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR CLAVICLE RT","30000077","CDM","320","RC","73000","HCPCS",,,"facility","inpatient",,,"RT","769","769",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR CLAVICLE RT","30000077","CDM","320","RC","73000","HCPCS",,,"facility","outpatient",,,"RT","769","769",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR SCAPULA BIL","30000078","CDM","320","RC","73010","HCPCS",,,"facility","inpatient",,,"50","1260","1260",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR SCAPULA BIL","30000078","CDM","320","RC","73010","HCPCS",,,"facility","outpatient",,,"50","1260","1260",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR SCAPULA LT","30000079","CDM","320","RC","73010","HCPCS",,,"facility","inpatient",,,"LT","840","840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR SCAPULA LT","30000079","CDM","320","RC","73010","HCPCS",,,"facility","outpatient",,,"LT","840","840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR SCAPULA RT","30000080","CDM","320","RC","73010","HCPCS",,,"facility","inpatient",,,"RT","840","840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR SCAPULA RT","30000080","CDM","320","RC","73010","HCPCS",,,"facility","outpatient",,,"RT","840","840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR SHOULDER 1 VIEW BIL","30000081","CDM","320","RC","73020","HCPCS",,,"facility","inpatient",,,"50","1040","1040",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR SHOULDER 1 VIEW BIL","30000081","CDM","320","RC","73020","HCPCS",,,"facility","outpatient",,,"50","1040","1040",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR SHOULDER 1 VIEW LT","30000082","CDM","320","RC","73020","HCPCS",,,"facility","inpatient",,,"LT","693","693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR SHOULDER 1 VIEW LT","30000082","CDM","320","RC","73020","HCPCS",,,"facility","outpatient",,,"LT","693","693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR SHOULDER 1 VIEW RT","30000083","CDM","320","RC","73020","HCPCS",,,"facility","inpatient",,,"RT","693","693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR SHOULDER 1 VIEW RT","30000083","CDM","320","RC","73020","HCPCS",,,"facility","outpatient",,,"RT","693","693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR SHOULDER 2 VIEW OR MORE BIL","30000084","CDM","320","RC","73030","HCPCS",,,"facility","inpatient",,,"50","1335","1335",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR SHOULDER 2 VIEW OR MORE BIL","30000084","CDM","320","RC","73030","HCPCS",,,"facility","outpatient",,,"50","1335","1335",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR SHOULDER 2 VIEW OR MORE LT","30000085","CDM","320","RC","73030","HCPCS",,,"facility","inpatient",,,"LT","890","890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR SHOULDER 2 VIEW OR MORE LT","30000085","CDM","320","RC","73030","HCPCS",,,"facility","outpatient",,,"LT","890","890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR SHOULDER 2 VIEW OR MORE RT","30000086","CDM","320","RC","73030","HCPCS",,,"facility","inpatient",,,"RT","890","890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR SHOULDER 2 VIEW OR MORE RT","30000086","CDM","320","RC","73030","HCPCS",,,"facility","outpatient",,,"RT","890","890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO SHOULDER BIL","30000087","CDM","322","RC","73040","HCPCS",,,"facility","inpatient",,,"50","2757","2757",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO SHOULDER BIL","30000087","CDM","322","RC","73040","HCPCS",,,"facility","outpatient",,,"50","2757","2757",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO SHOULDER LT","30000088","CDM","322","RC","73040","HCPCS",,,"facility","inpatient",,,"LT","1838","1838",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO SHOULDER LT","30000088","CDM","322","RC","73040","HCPCS",,,"facility","outpatient",,,"LT","1838","1838",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO SHOULDER RT","30000089","CDM","322","RC","73040","HCPCS",,,"facility","inpatient",,,"RT","1838","1838",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO SHOULDER RT","30000089","CDM","322","RC","73040","HCPCS",,,"facility","outpatient",,,"RT","1838","1838",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR AC JOINT","30000090","CDM","320","RC","73050","HCPCS",,,"facility","inpatient",,,,"733","733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR AC JOINT","30000090","CDM","320","RC","73050","HCPCS",,,"facility","outpatient",,,,"733","733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HUMERUS LT","30000092","CDM","320","RC","73060","HCPCS",,,"facility","inpatient",,,"LT","919","919",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR HUMERUS LT","30000092","CDM","320","RC","73060","HCPCS",,,"facility","outpatient",,,"LT","919","919",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR HUMERUS RT","30000093","CDM","320","RC","73060","HCPCS",,,"facility","inpatient",,,"RT","919","919",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR HUMERUS RT","30000093","CDM","320","RC","73060","HCPCS",,,"facility","outpatient",,,"RT","919","919",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ELBOW 2 VIEW BIL","30000094","CDM","320","RC","73070","HCPCS",,,"facility","inpatient",,,"50","1128","1128",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ELBOW 2 VIEW BIL","30000094","CDM","320","RC","73070","HCPCS",,,"facility","outpatient",,,"50","1128","1128",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ELBOW 2 VIEW LT","30000095","CDM","320","RC","73070","HCPCS",,,"facility","inpatient",,,"LT","752","752",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ELBOW 2 VIEW LT","30000095","CDM","320","RC","73070","HCPCS",,,"facility","outpatient",,,"LT","752","752",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ELBOW 2 VIEW RT","30000096","CDM","320","RC","73070","HCPCS",,,"facility","inpatient",,,"RT","752","752",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ELBOW 2 VIEW RT","30000096","CDM","320","RC","73070","HCPCS",,,"facility","outpatient",,,"RT","752","752",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ELBOW 3 VIEW OR MORE BIL","30000097","CDM","320","RC","73080","HCPCS",,,"facility","inpatient",,,"50","1265","1265",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ELBOW 3 VIEW OR MORE BIL","30000097","CDM","320","RC","73080","HCPCS",,,"facility","outpatient",,,"50","1265","1265",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ELBOW 3 VIEW OR MORE LT","30000098","CDM","320","RC","73080","HCPCS",,,"facility","inpatient",,,"LT","844","844",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ELBOW 3 VIEW OR MORE LT","30000098","CDM","320","RC","73080","HCPCS",,,"facility","outpatient",,,"LT","844","844",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ELBOW 3 VIEW OR MORE RT","30000099","CDM","320","RC","73080","HCPCS",,,"facility","inpatient",,,"RT","844","844",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ELBOW 3 VIEW OR MORE RT","30000099","CDM","320","RC","73080","HCPCS",,,"facility","outpatient",,,"RT","844","844",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO ELBOW BIL","30000100","CDM","322","RC","73085","HCPCS",,,"facility","inpatient",,,"50","7584","7584",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO ELBOW BIL","30000100","CDM","322","RC","73085","HCPCS",,,"facility","outpatient",,,"50","7584","7584",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO ELBOW LT","30000101","CDM","322","RC","73085","HCPCS",,,"facility","inpatient",,,"LT","5056","5056",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO ELBOW LT","30000101","CDM","322","RC","73085","HCPCS",,,"facility","outpatient",,,"LT","5056","5056",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO ELBOW RT","30000102","CDM","322","RC","73085","HCPCS",,,"facility","inpatient",,,"RT","5056","5056",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO ELBOW RT","30000102","CDM","322","RC","73085","HCPCS",,,"facility","outpatient",,,"RT","5056","5056",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR FOREARM BIL","30000103","CDM","320","RC","73090","HCPCS",,,"facility","inpatient",,,"50","1368","1368",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR FOREARM BIL","30000103","CDM","320","RC","73090","HCPCS",,,"facility","outpatient",,,"50","1368","1368",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR FOREARM LT","30000104","CDM","320","RC","73090","HCPCS",,,"facility","inpatient",,,"LT","912","912",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR FOREARM LT","30000104","CDM","320","RC","73090","HCPCS",,,"facility","outpatient",,,"LT","912","912",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR FOREARM RT","30000105","CDM","320","RC","73090","HCPCS",,,"facility","inpatient",,,"RT","912","912",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR FOREARM RT","30000105","CDM","320","RC","73090","HCPCS",,,"facility","outpatient",,,"RT","912","912",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARM INFANT (< 1 YEAR) BIL","30000106","CDM","320","RC","73092","HCPCS",,,"facility","inpatient",,,"50","974","974",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARM INFANT (< 1 YEAR) BIL","30000106","CDM","320","RC","73092","HCPCS",,,"facility","outpatient",,,"50","974","974",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARM INFANT (< 1 YEAR) LT","30000107","CDM","320","RC","73092","HCPCS",,,"facility","inpatient",,,"LT","649","649",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARM INFANT (< 1 YEAR) LT","30000107","CDM","320","RC","73092","HCPCS",,,"facility","outpatient",,,"LT","649","649",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARM INFANT (< 1 YEAR) RT","30000108","CDM","320","RC","73092","HCPCS",,,"facility","inpatient",,,"RT","649","649",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARM INFANT (< 1 YEAR) RT","30000108","CDM","320","RC","73092","HCPCS",,,"facility","outpatient",,,"RT","649","649",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR WRIST 2 VIEW BIL","30000109","CDM","320","RC","73100","HCPCS",,,"facility","inpatient",,,"50","1012","1012",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR WRIST 2 VIEW BIL","30000109","CDM","320","RC","73100","HCPCS",,,"facility","outpatient",,,"50","1012","1012",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR WRIST 2 VIEW LT","30000110","CDM","320","RC","73100","HCPCS",,,"facility","inpatient",,,"LT","675","675",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR WRIST 2 VIEW LT","30000110","CDM","320","RC","73100","HCPCS",,,"facility","outpatient",,,"LT","675","675",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR WRIST 2 VIEW RT","30000111","CDM","320","RC","73100","HCPCS",,,"facility","inpatient",,,"RT","675","675",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR WRIST 2 VIEW RT","30000111","CDM","320","RC","73100","HCPCS",,,"facility","outpatient",,,"RT","675","675",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR WRIST 3 VIEW OR MORE BIL","30000112","CDM","320","RC","73110","HCPCS",,,"facility","inpatient",,,"50","1294","1294",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR WRIST 3 VIEW OR MORE BIL","30000112","CDM","320","RC","73110","HCPCS",,,"facility","outpatient",,,"50","1294","1294",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR WRIST 3 VIEW OR MORE LT","30000113","CDM","320","RC","73110","HCPCS",,,"facility","inpatient",,,"LT","862","862",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR WRIST 3 VIEW OR MORE LT","30000113","CDM","320","RC","73110","HCPCS",,,"facility","outpatient",,,"LT","862","862",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR WRIST 3 VIEW OR MORE RT","30000114","CDM","320","RC","73110","HCPCS",,,"facility","inpatient",,,"RT","862","862",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR WRIST 3 VIEW OR MORE RT","30000114","CDM","320","RC","73110","HCPCS",,,"facility","outpatient",,,"RT","862","862",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO WRIST BIL","30000115","CDM","322","RC","73115","HCPCS",,,"facility","inpatient",,,"50","1594","1594",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO WRIST BIL","30000115","CDM","322","RC","73115","HCPCS",,,"facility","outpatient",,,"50","1594","1594",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO WRIST LT","30000116","CDM","322","RC","73115","HCPCS",,,"facility","inpatient",,,"LT","1063","1063",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO WRIST LT","30000116","CDM","322","RC","73115","HCPCS",,,"facility","outpatient",,,"LT","1063","1063",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO WRIST RT","30000117","CDM","322","RC","73115","HCPCS",,,"facility","inpatient",,,"RT","1063","1063",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO WRIST RT","30000117","CDM","322","RC","73115","HCPCS",,,"facility","outpatient",,,"RT","1063","1063",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR HAND 2 VIEW BIL","30000118","CDM","320","RC","73120","HCPCS",,,"facility","inpatient",,,"50","1202","1202",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR HAND 2 VIEW BIL","30000118","CDM","320","RC","73120","HCPCS",,,"facility","outpatient",,,"50","1202","1202",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR HAND 2 VIEW LT","30000119","CDM","320","RC","73120","HCPCS",,,"facility","inpatient",,,"LT","801","801",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR HAND 2 VIEW LT","30000119","CDM","320","RC","73120","HCPCS",,,"facility","outpatient",,,"LT","801","801",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR HAND 2 VIEW RT","30000120","CDM","320","RC","73120","HCPCS",,,"facility","inpatient",,,"RT","801","801",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR HAND 2 VIEW RT","30000120","CDM","320","RC","73120","HCPCS",,,"facility","outpatient",,,"RT","801","801",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR HAND 3 VIEW OR MORE BIL","30000121","CDM","320","RC","73130","HCPCS",,,"facility","inpatient",,,"50","1329","1329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR HAND 3 VIEW OR MORE BIL","30000121","CDM","320","RC","73130","HCPCS",,,"facility","outpatient",,,"50","1329","1329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR HAND 3 VIEW OR MORE LT","30000122","CDM","320","RC","73130","HCPCS",,,"facility","inpatient",,,"LT","886","886",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR HAND 3 VIEW OR MORE LT","30000122","CDM","320","RC","73130","HCPCS",,,"facility","outpatient",,,"LT","886","886",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR HAND 3 VIEW OR MORE RT","30000123","CDM","320","RC","73130","HCPCS",,,"facility","inpatient",,,"RT","886","886",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR HAND 3 VIEW OR MORE RT","30000123","CDM","320","RC","73130","HCPCS",,,"facility","outpatient",,,"RT","886","886",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR FINGER(S) 2 VIEW OR MORE LT","30000124","CDM","320","RC","73140","HCPCS",,,"facility","inpatient",,,"LT","681","681",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR FINGER(S) 2 VIEW OR MORE LT","30000124","CDM","320","RC","73140","HCPCS",,,"facility","outpatient",,,"LT","681","681",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO HIP LT","30000130","CDM","322","RC","73525","HCPCS",,,"facility","inpatient",,,"LT","2090","2090",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO HIP LT","30000130","CDM","322","RC","73525","HCPCS",,,"facility","outpatient",,,"LT","2090","2090",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO HIP RT","30000131","CDM","322","RC","73525","HCPCS",,,"facility","inpatient",,,"RT","2090","2090",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO HIP RT","30000131","CDM","322","RC","73525","HCPCS",,,"facility","outpatient",,,"RT","2090","2090",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO HIP BIL","30000132","CDM","322","RC","73525","HCPCS",,,"facility","inpatient",,,"50","3135","3135",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO HIP BIL","30000132","CDM","322","RC","73525","HCPCS",,,"facility","outpatient",,,"50","3135","3135",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR KNEE 1 OR 2 VIEW BIL","30000140","CDM","320","RC","73560","HCPCS",,,"facility","inpatient",,,"50","1064","1064",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR KNEE 1 OR 2 VIEW BIL","30000140","CDM","320","RC","73560","HCPCS",,,"facility","outpatient",,,"50","1064","1064",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR KNEE 1 OR 2 VIEW LT","30000141","CDM","320","RC","73560","HCPCS",,,"facility","inpatient",,,"LT","709","709",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR KNEE 1 OR 2 VIEW LT","30000141","CDM","320","RC","73560","HCPCS",,,"facility","outpatient",,,"LT","709","709",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR KNEE 1 OR 2 VIEW RT","30000142","CDM","320","RC","73560","HCPCS",,,"facility","inpatient",,,"RT","709","709",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR KNEE 1 OR 2 VIEW RT","30000142","CDM","320","RC","73560","HCPCS",,,"facility","outpatient",,,"RT","709","709",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR KNEE 3 VIEW BIL","30000143","CDM","320","RC","73562","HCPCS",,,"facility","inpatient",,,"50","1431","1431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR KNEE 3 VIEW BIL","30000143","CDM","320","RC","73562","HCPCS",,,"facility","outpatient",,,"50","1431","1431",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR KNEE 3 VIEW LT","30000144","CDM","320","RC","73562","HCPCS",,,"facility","inpatient",,,"LT","954","954",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR KNEE 3 VIEW LT","30000144","CDM","320","RC","73562","HCPCS",,,"facility","outpatient",,,"LT","954","954",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR KNEE 3 VIEW RT","30000145","CDM","320","RC","73562","HCPCS",,,"facility","inpatient",,,"RT","954","954",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR KNEE 3 VIEW RT","30000145","CDM","320","RC","73562","HCPCS",,,"facility","outpatient",,,"RT","954","954",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR KNEE 4 VIEW OR MORE BIL","30000146","CDM","320","RC","73564","HCPCS",,,"facility","inpatient",,,"50","1537","1537",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR KNEE 4 VIEW OR MORE BIL","30000146","CDM","320","RC","73564","HCPCS",,,"facility","outpatient",,,"50","1537","1537",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR KNEE 4 VIEW OR MORE LT","30000147","CDM","320","RC","73564","HCPCS",,,"facility","inpatient",,,"LT","1025","1025",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR KNEE 4 VIEW OR MORE LT","30000147","CDM","320","RC","73564","HCPCS",,,"facility","outpatient",,,"LT","1025","1025",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR KNEE 4 VIEW OR MORE RT","30000148","CDM","320","RC","73564","HCPCS",,,"facility","inpatient",,,"RT","1025","1025",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR KNEE 4 VIEW OR MORE RT","30000148","CDM","320","RC","73564","HCPCS",,,"facility","outpatient",,,"RT","1025","1025",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR KNEES BOTH STANDING AP","30000149","CDM","320","RC","73565","HCPCS",,,"facility","inpatient",,,,"622","622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR KNEES BOTH STANDING AP","30000149","CDM","320","RC","73565","HCPCS",,,"facility","outpatient",,,,"622","622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ARTHRO KNEE BIL","30000152","CDM","322","RC","73580","HCPCS",,,"facility","inpatient",,,"50","2838","2838",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO KNEE BIL","30000152","CDM","322","RC","73580","HCPCS",,,"facility","outpatient",,,"50","2838","2838",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR TIBIA FIBULA BIL","30000153","CDM","320","RC","73590","HCPCS",,,"facility","inpatient",,,"50","1215","1215",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR TIBIA FIBULA BIL","30000153","CDM","320","RC","73590","HCPCS",,,"facility","outpatient",,,"50","1215","1215",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR TIBIA FIBULA LT","30000154","CDM","320","RC","73590","HCPCS",,,"facility","inpatient",,,"LT","810","810",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR TIBIA FIBULA LT","30000154","CDM","320","RC","73590","HCPCS",,,"facility","outpatient",,,"LT","810","810",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR TIBIA FIBULA RT","30000155","CDM","320","RC","73590","HCPCS",,,"facility","inpatient",,,"RT","810","810",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR TIBIA FIBULA RT","30000155","CDM","320","RC","73590","HCPCS",,,"facility","outpatient",,,"RT","810","810",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR LEG INFANT (< 1 YEAR) BIL","30000156","CDM","320","RC","73592","HCPCS",,,"facility","inpatient",,,"50","970","970",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR LEG INFANT (< 1 YEAR) BIL","30000156","CDM","320","RC","73592","HCPCS",,,"facility","outpatient",,,"50","970","970",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR LEG INFANT (< 1 YEAR) LT","30000157","CDM","320","RC","73592","HCPCS",,,"facility","inpatient",,,"LT","647","647",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR LEG INFANT (< 1 YEAR) LT","30000157","CDM","320","RC","73592","HCPCS",,,"facility","outpatient",,,"LT","647","647",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR LEG INFANT (< 1 YEAR) RT","30000158","CDM","320","RC","73592","HCPCS",,,"facility","inpatient",,,"RT","647","647",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR LEG INFANT (< 1 YEAR) RT","30000158","CDM","320","RC","73592","HCPCS",,,"facility","outpatient",,,"RT","647","647",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ANKLE 2 VIEW BIL","30000159","CDM","320","RC","73600","HCPCS",,,"facility","inpatient",,,"50","1115","1115",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ANKLE 2 VIEW BIL","30000159","CDM","320","RC","73600","HCPCS",,,"facility","outpatient",,,"50","1115","1115",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ANKLE 2 VIEW LT","30000160","CDM","320","RC","73600","HCPCS",,,"facility","inpatient",,,"LT","743","743",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ANKLE 2 VIEW LT","30000160","CDM","320","RC","73600","HCPCS",,,"facility","outpatient",,,"LT","743","743",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ANKLE 2 VIEW RT","30000161","CDM","320","RC","73600","HCPCS",,,"facility","inpatient",,,"RT","743","743",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ANKLE 2 VIEW RT","30000161","CDM","320","RC","73600","HCPCS",,,"facility","outpatient",,,"RT","743","743",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ANKLE 3 VIEW OR MORE BIL","30000162","CDM","320","RC","73610","HCPCS",,,"facility","inpatient",,,"50","1300","1300",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ANKLE 3 VIEW OR MORE BIL","30000162","CDM","320","RC","73610","HCPCS",,,"facility","outpatient",,,"50","1300","1300",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ANKLE 3 VIEW OR MORE LT","30000163","CDM","320","RC","73610","HCPCS",,,"facility","inpatient",,,"LT","866","866",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ANKLE 3 VIEW OR MORE LT","30000163","CDM","320","RC","73610","HCPCS",,,"facility","outpatient",,,"LT","866","866",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ANKLE 3 VIEW OR MORE RT","30000164","CDM","320","RC","73610","HCPCS",,,"facility","inpatient",,,"RT","866","866",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ANKLE 3 VIEW OR MORE RT","30000164","CDM","320","RC","73610","HCPCS",,,"facility","outpatient",,,"RT","866","866",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO ANKLE LT","30000165","CDM","322","RC","73615","HCPCS",,,"facility","inpatient",,,"LT","7309","7309",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO ANKLE LT","30000165","CDM","322","RC","73615","HCPCS",,,"facility","outpatient",,,"LT","7309","7309",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR ARTHRO ANKLE RT","30000166","CDM","322","RC","73615","HCPCS",,,"facility","inpatient",,,"RT","7309","7309",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO ANKLE RT","30000166","CDM","322","RC","73615","HCPCS",,,"facility","outpatient",,,"RT","7309","7309",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR ARTHRO ANKLE BIL","30000167","CDM","322","RC","73615","HCPCS",,,"facility","inpatient",,,"50","10964","10964",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR ARTHRO ANKLE BIL","30000167","CDM","322","RC","73615","HCPCS",,,"facility","outpatient",,,"50","10964","10964",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR FOOT 2 VIEW BIL","30000168","CDM","320","RC","73620","HCPCS",,,"facility","inpatient",,,"50","1046","1046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR FOOT 2 VIEW BIL","30000168","CDM","320","RC","73620","HCPCS",,,"facility","outpatient",,,"50","1046","1046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR FOOT 2 VIEW LT","30000169","CDM","320","RC","73620","HCPCS",,,"facility","inpatient",,,"LT","698","698",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR FOOT 2 VIEW LT","30000169","CDM","320","RC","73620","HCPCS",,,"facility","outpatient",,,"LT","698","698",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR FOOT 2 VIEW RT","30000170","CDM","320","RC","73620","HCPCS",,,"facility","inpatient",,,"RT","698","698",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR FOOT 2 VIEW RT","30000170","CDM","320","RC","73620","HCPCS",,,"facility","outpatient",,,"RT","698","698",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR FOOT 3 VIEW OR MORE BIL","30000171","CDM","320","RC","73630","HCPCS",,,"facility","inpatient",,,"50","1377","1377",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR FOOT 3 VIEW OR MORE BIL","30000171","CDM","320","RC","73630","HCPCS",,,"facility","outpatient",,,"50","1377","1377",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR FOOT 3 VIEW OR MORE LT","30000172","CDM","320","RC","73630","HCPCS",,,"facility","inpatient",,,"LT","918","918",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR FOOT 3 VIEW OR MORE LT","30000172","CDM","320","RC","73630","HCPCS",,,"facility","outpatient",,,"LT","918","918",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR FOOT 3 VIEW OR MORE RT","30000173","CDM","320","RC","73630","HCPCS",,,"facility","inpatient",,,"RT","918","918",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR FOOT 3 VIEW OR MORE RT","30000173","CDM","320","RC","73630","HCPCS",,,"facility","outpatient",,,"RT","918","918",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR CALCANEUS 2 VIEW OR MORE BIL","30000174","CDM","320","RC","73650","HCPCS",,,"facility","inpatient",,,"50","963","963",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR CALCANEUS 2 VIEW OR MORE BIL","30000174","CDM","320","RC","73650","HCPCS",,,"facility","outpatient",,,"50","963","963",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR CALCANEUS 2 VIEW OR MORE LT","30000175","CDM","320","RC","73650","HCPCS",,,"facility","inpatient",,,"LT","642","642",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR CALCANEUS 2 VIEW OR MORE LT","30000175","CDM","320","RC","73650","HCPCS",,,"facility","outpatient",,,"LT","642","642",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR CALCANEUS 2 VIEW OR MORE RT","30000176","CDM","320","RC","73650","HCPCS",,,"facility","inpatient",,,"RT","642","642",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR CALCANEUS 2 VIEW OR MORE RT","30000176","CDM","320","RC","73650","HCPCS",,,"facility","outpatient",,,"RT","642","642",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR TOE(S) 2 VIEW OR MORE LT","30000177","CDM","320","RC","73660","HCPCS",,,"facility","inpatient",,,"LT","662","662",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR TOE(S) 2 VIEW OR MORE LT","30000177","CDM","320","RC","73660","HCPCS",,,"facility","outpatient",,,"LT","662","662",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR CMPL ACUTE ABD 2+ VIEWS W/1 VIEW CHEST","30000181","CDM","320","RC","74022","HCPCS",,,"facility","inpatient",,,,"1179","1179",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CMPL ACUTE ABD 2+ VIEWS W/1 VIEW CHEST","30000181","CDM","320","RC","74022","HCPCS",,,"facility","outpatient",,,,"1179","1179",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ESOPHAGUS 1CNTRST STUDY (BARIUM SWALLOW)","30000183","CDM","320","RC","74220","HCPCS",,,"facility","inpatient",,,,"1422","1422",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ESOPHAGUS 1CNTRST STUDY (BARIUM SWALLOW)","30000183","CDM","320","RC","74220","HCPCS",,,"facility","outpatient",,,,"1422","1422",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SWALLOWING FUNCTION CONTRAST STUDY","30000184","CDM","320","RC","74230","HCPCS",,,"facility","inpatient",,,,"1571","1571",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SWALLOWING FUNCTION CONTRAST STUDY","30000184","CDM","320","RC","74230","HCPCS",,,"facility","outpatient",,,,"1571","1571",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR UGI TRC SINGLE CONTRAST STUDY","30000185","CDM","320","RC","74240","HCPCS",,,"facility","inpatient",,,,"1658","1658",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR UGI TRC SINGLE CONTRAST STUDY","30000185","CDM","320","RC","74240","HCPCS",,,"facility","outpatient",,,,"1658","1658",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR UGI TRC DOUBLE CONTRAST STUDY","30000188","CDM","320","RC","74246","HCPCS",,,"facility","inpatient",,,,"1643","1643",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR UGI TRC DOUBLE CONTRAST STUDY","30000188","CDM","320","RC","74246","HCPCS",,,"facility","outpatient",,,,"1643","1643",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SM BOWEL SINGLE CONTRAST STUDY","30000191","CDM","320","RC","74250","HCPCS",,,"facility","inpatient",,,,"1744","1744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SM BOWEL SINGLE CONTRAST STUDY","30000191","CDM","320","RC","74250","HCPCS",,,"facility","outpatient",,,,"1744","1744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR COLON SINGLE CONTRAST STUDY","30000193","CDM","320","RC","74270","HCPCS",,,"facility","inpatient",,,,"1630","1630",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR COLON SINGLE CONTRAST STUDY","30000193","CDM","320","RC","74270","HCPCS",,,"facility","outpatient",,,,"1630","1630",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR COLON DOUBLE CONTRAST STUDY","30000194","CDM","320","RC","74280","HCPCS",,,"facility","inpatient",,,,"2003","2003",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR COLON DOUBLE CONTRAST STUDY","30000194","CDM","320","RC","74280","HCPCS",,,"facility","outpatient",,,,"2003","2003",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BE THERP","30000195","CDM","320","RC","74283","HCPCS",,,"facility","inpatient",,,,"3711","3711",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BE THERP","30000195","CDM","320","RC","74283","HCPCS",,,"facility","outpatient",,,,"3711","3711",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHOLECYSTOG ORAL","30000196","CDM","320","RC","74290","HCPCS",,,"facility","inpatient",,,,"2009","2009",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHOLECYSTOG ORAL","30000196","CDM","320","RC","74290","HCPCS",,,"facility","outpatient",,,,"2009","2009",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHOLE OPPR","30000198","CDM","320","RC","74300","HCPCS",,,"facility","inpatient",,,,"1976","1976",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHOLE OPPR","30000198","CDM","320","RC","74300","HCPCS",,,"facility","outpatient",,,,"1976","1976",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHOLE OPPR EA ADDITIONAL","30000199","CDM","320","RC","74301","HCPCS",,,"facility","inpatient",,,,"766","766",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHOLE OPPR EA ADDITIONAL","30000199","CDM","320","RC","74301","HCPCS",,,"facility","outpatient",,,,"766","766",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST 1ST STRTCTC","30000200","CDM","361","RC","19283","HCPCS",,,"facility","inpatient",,,,"2239","2239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST 1ST STRTCTC","30000200","CDM","361","RC","19283","HCPCS",,,"facility","outpatient",,,,"2239","2239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST ADD STRTCTC","30000203","CDM","361","RC","19284","HCPCS",,,"facility","inpatient",,,,"2759","2759",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST ADD STRTCTC","30000203","CDM","361","RC","19284","HCPCS",,,"facility","outpatient",,,,"2759","2759",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST 1ST US IMAG","30000204","CDM","361","RC","19285","HCPCS",,,"facility","inpatient",,,,"3196","3196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST 1ST US IMAG","30000204","CDM","361","RC","19285","HCPCS",,,"facility","outpatient",,,,"3196","3196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST ADD US IMAG","30000205","CDM","361","RC","19286","HCPCS",,,"facility","inpatient",,,,"986","986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST ADD US IMAG","30000205","CDM","361","RC","19286","HCPCS",,,"facility","outpatient",,,,"986","986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR GI TUBE INSERT LONG","30000206","CDM","320","RC","74340","HCPCS",,,"facility","inpatient",,,,"1711","1711",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR GI TUBE INSERT LONG","30000206","CDM","320","RC","74340","HCPCS",,,"facility","outpatient",,,,"1711","1711",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST 1ST MR GUIDE","30000207","CDM","361","RC","19287","HCPCS",,,"facility","inpatient",,,,"2332","2332",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST 1ST MR GUIDE","30000207","CDM","361","RC","19287","HCPCS",,,"facility","outpatient",,,,"2332","2332",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ENTEROCLYSIS TUBE PERC","30000208","CDM","320","RC","74355","HCPCS",,,"facility","inpatient",,,,"3163","3163",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ENTEROCLYSIS TUBE PERC","30000208","CDM","320","RC","74355","HCPCS",,,"facility","outpatient",,,,"3163","3163",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST ADD MR GUIDE","30000209","CDM","361","RC","19288","HCPCS",,,"facility","inpatient",,,,"437","437",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV BREAST ADD MR GUIDE","30000209","CDM","361","RC","19288","HCPCS",,,"facility","outpatient",,,,"437","437",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR IVP W WO TOMOG","30000210","CDM","320","RC","74400","HCPCS",,,"facility","inpatient",,,,"1236","1236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR IVP W WO TOMOG","30000210","CDM","320","RC","74400","HCPCS",,,"facility","outpatient",,,,"1236","1236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR IVP DRIP / BOLUS","30000211","CDM","320","RC","74410","HCPCS",,,"facility","inpatient",,,,"2636","2636",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR IVP DRIP / BOLUS","30000211","CDM","320","RC","74410","HCPCS",,,"facility","outpatient",,,,"2636","2636",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR IVP W NEPHROTOMOG","30000212","CDM","320","RC","74415","HCPCS",,,"facility","inpatient",,,,"3033","3033",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR IVP W NEPHROTOMOG","30000212","CDM","320","RC","74415","HCPCS",,,"facility","outpatient",,,,"3033","3033",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR UROG RETROGRADE W WO KUB","30000213","CDM","320","RC","74420","HCPCS",,,"facility","inpatient",,,,"2719","2719",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR UROG RETROGRADE W WO KUB","30000213","CDM","320","RC","74420","HCPCS",,,"facility","outpatient",,,,"2719","2719",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR UROG ANTEGRADE","30000214","CDM","320","RC","74425","HCPCS",,,"facility","inpatient",,,,"2106","2106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR UROG ANTEGRADE","30000214","CDM","320","RC","74425","HCPCS",,,"facility","outpatient",,,,"2106","2106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CYSTOG 3 VIEW OR MORE","30000215","CDM","320","RC","74430","HCPCS",,,"facility","inpatient",,,,"1268","1268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CYSTOG 3 VIEW OR MORE","30000215","CDM","320","RC","74430","HCPCS",,,"facility","outpatient",,,,"1268","1268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VASOGRAM VESICULOGRAM","30000216","CDM","320","RC","74440","HCPCS",,,"facility","inpatient",,,,"2266","2266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VASOGRAM VESICULOGRAM","30000216","CDM","320","RC","74440","HCPCS",,,"facility","outpatient",,,,"2266","2266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR URETHROCYSTOG RETROGRADE","30000217","CDM","320","RC","74450","HCPCS",,,"facility","inpatient",,,,"1911","1911",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR URETHROCYSTOG RETROGRADE","30000217","CDM","320","RC","74450","HCPCS",,,"facility","outpatient",,,,"1911","1911",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR URETHROCYSTOGRAM VOIDING","30000218","CDM","320","RC","74455","HCPCS",,,"facility","inpatient",,,,"1633","1633",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR URETHROCYSTOGRAM VOIDING","30000218","CDM","320","RC","74455","HCPCS",,,"facility","outpatient",,,,"1633","1633",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR RENAL CYST STUDY","30000219","CDM","320","RC","74470","HCPCS",,,"facility","inpatient",,,,"1319","1319",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR RENAL CYST STUDY","30000219","CDM","320","RC","74470","HCPCS",,,"facility","outpatient",,,,"1319","1319",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HYSTEROSALPINGOGRAM","30000222","CDM","320","RC","74740","HCPCS",,,"facility","inpatient",,,,"1432","1432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HYSTEROSALPINGOGRAM","30000222","CDM","320","RC","74740","HCPCS",,,"facility","outpatient",,,,"1432","1432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TRANSCERVICAL CATH OF FALLOPIAN TUBE","30000223","CDM","320","RC","74742","HCPCS",,,"facility","inpatient",,,,"1953","1953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TRANSCERVICAL CATH OF FALLOPIAN TUBE","30000223","CDM","320","RC","74742","HCPCS",,,"facility","outpatient",,,,"1953","1953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DXA BONE DENSITY STUDY","30000237","CDM","320","RC","77085","HCPCS",,,"facility","inpatient",,,,"794","794",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DXA BONE DENSITY STUDY","30000237","CDM","320","RC","77085","HCPCS",,,"facility","outpatient",,,,"794","794",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRACTURE ASSESSMENT VIA DXA","30000238","CDM","320","RC","77086","HCPCS",,,"facility","inpatient",,,,"389","389",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRACTURE ASSESSMENT VIA DXA","30000238","CDM","320","RC","77086","HCPCS",,,"facility","outpatient",,,,"389","389",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BREAST TOMOSYNTHESIS DX UNI","30000239","CDM","401","RC","G0279","HCPCS",,,"facility","inpatient",,,,"188","188",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BREAST TOMOSYNTHESIS DX UNI","30000239","CDM","401","RC","G0279","HCPCS",,,"facility","outpatient",,,,"188","188",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FB LOCALIZATION CH","30000242","CDM","320","RC","76010","HCPCS",,,"facility","inpatient",,,,"503","503",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FB LOCALIZATION CH","30000242","CDM","320","RC","76010","HCPCS",,,"facility","outpatient",,,,"503","503",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABSCESS FISTULA SINUS TRACT","30000243","CDM","320","RC","76080","HCPCS",,,"facility","inpatient",,,,"1934","1934",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABSCESS FISTULA SINUS TRACT","30000243","CDM","320","RC","76080","HCPCS",,,"facility","outpatient",,,,"1934","1934",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPECIMEN SURGICAL","30000244","CDM","320","RC","76098","HCPCS",,,"facility","inpatient",,,,"1281","1281",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPECIMEN SURGICAL","30000244","CDM","320","RC","76098","HCPCS",,,"facility","outpatient",,,,"1281","1281",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TOMOGRAM","30000245","CDM","320","RC","76100","HCPCS",,,"facility","inpatient",,,,"2355","2355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TOMOGRAM","30000245","CDM","320","RC","76100","HCPCS",,,"facility","outpatient",,,,"2355","2355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAMMARY GALACTOGRAM OR DUCTOGRAM 1 DUCT","30000255","CDM","320","RC","77053","HCPCS",,,"facility","inpatient",,,,"998","998",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAMMARY GALACTOGRAM OR DUCTOGRAM 1 DUCT","30000255","CDM","320","RC","77053","HCPCS",,,"facility","outpatient",,,,"998","998",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR GALACTOG MULT DUCTS","30000256","CDM","320","RC","77054","HCPCS",,,"facility","inpatient",,,,"2822","2822",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR GALACTOG MULT DUCTS","30000256","CDM","320","RC","77054","HCPCS",,,"facility","outpatient",,,,"2822","2822",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAN APP STRS ANY JNT","30000260","CDM","320","RC","77071","HCPCS",,,"facility","inpatient",,,,"735","735",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAN APP STRS ANY JNT","30000260","CDM","320","RC","77071","HCPCS",,,"facility","outpatient",,,,"735","735",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE AGE STUDY","30000261","CDM","320","RC","77072","HCPCS",,,"facility","inpatient",,,,"458","458",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE AGE STUDY","30000261","CDM","320","RC","77072","HCPCS",,,"facility","outpatient",,,,"458","458",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE LENGTH STUDY","30000262","CDM","320","RC","77073","HCPCS",,,"facility","inpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE LENGTH STUDY","30000262","CDM","320","RC","77073","HCPCS",,,"facility","outpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE SURVEY LTD","30000263","CDM","320","RC","77074","HCPCS",,,"facility","inpatient",,,,"869","869",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE SURVEY LTD","30000263","CDM","320","RC","77074","HCPCS",,,"facility","outpatient",,,,"869","869",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE SURVEY COMPLETE","30000264","CDM","320","RC","77075","HCPCS",,,"facility","inpatient",,,,"1521","1521",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE SURVEY COMPLETE","30000264","CDM","320","RC","77075","HCPCS",,,"facility","outpatient",,,,"1521","1521",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE SURVEY INFANT","30000265","CDM","320","RC","77076","HCPCS",,,"facility","inpatient",,,,"1786","1786",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BONE SURVEY INFANT","30000265","CDM","320","RC","77076","HCPCS",,,"facility","outpatient",,,,"1786","1786",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR JOINT SURVEY 1 VIEW","30000266","CDM","320","RC","77077","HCPCS",,,"facility","inpatient",,,,"618","618",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR JOINT SURVEY 1 VIEW","30000266","CDM","320","RC","77077","HCPCS",,,"facility","outpatient",,,,"618","618",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DEXA HIP, SPINE, AND/OR PELVIS","30000267","CDM","320","RC","77080","HCPCS",,,"facility","inpatient",,,,"913","913",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DEXA HIP, SPINE, AND/OR PELVIS","30000267","CDM","320","RC","77080","HCPCS",,,"facility","outpatient",,,,"913","913",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR EXAM OF MIDDLE EAR","30000275","CDM","320","RC","70134","HCPCS",,,"facility","inpatient",,,,"1048","1048",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR EXAM OF MIDDLE EAR","30000275","CDM","320","RC","70134","HCPCS",,,"facility","outpatient",,,,"1048","1048",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PELVIMETRY","30000286","CDM","320","RC","74710","HCPCS",,,"facility","inpatient",,,,"837","837",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PELVIMETRY","30000286","CDM","320","RC","74710","HCPCS",,,"facility","outpatient",,,,"837","837",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PERINEOGRAM","30000287","CDM","320","RC","74775","HCPCS",,,"facility","inpatient",,,,"463","463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PERINEOGRAM","30000287","CDM","320","RC","74775","HCPCS",,,"facility","outpatient",,,,"463","463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR LYMPHANGIOGRAM EXT UNILATERAL LT","30000288","CDM","320","RC","75801","HCPCS",,,"facility","inpatient",,,"LT","9693","9693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR LYMPHANGIOGRAM EXT UNILATERAL LT","30000288","CDM","320","RC","75801","HCPCS",,,"facility","outpatient",,,"LT","9693","9693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR LYMPHANGIO PELV BIL","30000291","CDM","320","RC","75807","HCPCS",,,"facility","inpatient",,,,"9447","9447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR LYMPHANGIO PELV BIL","30000291","CDM","320","RC","75807","HCPCS",,,"facility","outpatient",,,,"9447","9447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TOMOGRAM CMPLX LT","30000293","CDM","320","RC","76101","HCPCS",,,"facility","outpatient",,,"LT","2659","2659",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR TOMOGRAM CMPLX RT","30000294","CDM","320","RC","76101","HCPCS",,,"facility","outpatient",,,"RT","2659","2659",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR DEXA APPEN","30000297","CDM","320","RC","77081","HCPCS",,,"facility","inpatient",,,,"474","474",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DEXA APPEN","30000297","CDM","320","RC","77081","HCPCS",,,"facility","outpatient",,,,"474","474",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BREAST TOMOSYNTHESIS DX BI","30000299","CDM","401","RC","G0279","HCPCS",,,"facility","inpatient",,,,"282","282",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BREAST TOMOSYNTHESIS DX BI","30000299","CDM","401","RC","G0279","HCPCS",,,"facility","outpatient",,,,"282","282",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FOOT 1 VW BIL ARTHRITIS","30000301","CDM","320","RC","73620","HCPCS",,,"facility","inpatient",,,"50,52","1046","1046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure | Modifier 52: Reduced Services"
"HCHG XR FOOT 1 VW BIL ARTHRITIS","30000301","CDM","320","RC","73620","HCPCS",,,"facility","outpatient",,,"50,52","1046","1046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure | Modifier 52: Reduced Services"
"HCHG REPLACE G-J TUBE PERC","30000305","CDM","361","RC","49452","HCPCS",,,"facility","inpatient",,,,"3495","3495",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE G-J TUBE PERC","30000305","CDM","361","RC","49452","HCPCS",,,"facility","outpatient",,,,"3495","3495",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BREAST TOMOSYNTHESIS SCREEN BI","30000306","CDM","403","RC","77063","HCPCS",,,"facility","inpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BREAST TOMOSYNTHESIS SCREEN BI","30000306","CDM","403","RC","77063","HCPCS",,,"facility","outpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP BIL W/WO PELVIS 2 VIEWS","30000317","CDM","320","RC","73521","HCPCS",,,"facility","inpatient",,,,"959","959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP BIL W/WO PELVIS 2 VIEWS","30000317","CDM","320","RC","73521","HCPCS",,,"facility","outpatient",,,,"959","959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR EXAM OF FEMUR 1 VIEW LT","30000318","CDM","320","RC","73551","HCPCS",,,"facility","inpatient",,,"LT","714","714",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR EXAM OF FEMUR 1 VIEW LT","30000318","CDM","320","RC","73551","HCPCS",,,"facility","outpatient",,,"LT","714","714",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR HIP BIL W/WO PELVIS 3-4 VIEWS","30000324","CDM","320","RC","73522","HCPCS",,,"facility","inpatient",,,,"1136","1136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP BIL W/WO PELVIS 3-4 VIEWS","30000324","CDM","320","RC","73522","HCPCS",,,"facility","outpatient",,,,"1136","1136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP BIL W/WO PELVIS MIN 5 VIEWS","30000325","CDM","320","RC","73523","HCPCS",,,"facility","inpatient",,,,"1337","1337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP BIL W/WO PELVIS MIN 5 VIEWS","30000325","CDM","320","RC","73523","HCPCS",,,"facility","outpatient",,,,"1337","1337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR EXAM FEMUR MIN 2 VIEWS LT","30000326","CDM","320","RC","73552","HCPCS",,,"facility","inpatient",,,"LT","797","797",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR EXAM FEMUR MIN 2 VIEWS LT","30000326","CDM","320","RC","73552","HCPCS",,,"facility","outpatient",,,"LT","797","797",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR EXAM OF FEMUR 1 VIEW RT","30000341","CDM","320","RC","73551","HCPCS",,,"facility","inpatient",,,"RT","714","714",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR EXAM OF FEMUR 1 VIEW RT","30000341","CDM","320","RC","73551","HCPCS",,,"facility","outpatient",,,"RT","714","714",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR EXAM FEMUR MIN 2 VIEWS RT","30000342","CDM","320","RC","73552","HCPCS",,,"facility","inpatient",,,"RT","797","797",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR EXAM FEMUR MIN 2 VIEWS RT","30000342","CDM","320","RC","73552","HCPCS",,,"facility","outpatient",,,"RT","797","797",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG X-RAY EXAM OF FEMUR 1 VIEW BIL","30000349","CDM","320","RC","73551","HCPCS",,,"facility","inpatient",,,"50","1071","1071",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG X-RAY EXAM OF FEMUR 1 VIEW BIL","30000349","CDM","320","RC","73551","HCPCS",,,"facility","outpatient",,,"50","1071","1071",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR EXAM FEMUR MIN 2 VIEWS BIL","30000350","CDM","320","RC","73552","HCPCS",,,"facility","inpatient",,,"50","1195","1195",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR EXAM FEMUR MIN 2 VIEWS BIL","30000350","CDM","320","RC","73552","HCPCS",,,"facility","outpatient",,,"50","1195","1195",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BX BREAST 1ST LESION US IMAG LT","30000351","CDM","361","RC","19083","HCPCS",,,"facility","outpatient",,,"LT","5467","5467",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BX BREAST 1ST LESION US IMAG RT","30000352","CDM","361","RC","19083","HCPCS",,,"facility","outpatient",,,"RT","5467","5467",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BX BREAST ADD LESION US IMAG LT","30000353","CDM","361","RC","19084","HCPCS",,,"facility","outpatient",,,"LT","3118","3118",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BX BREAST ADD LESION US IMAG RT","30000354","CDM","361","RC","19084","HCPCS",,,"facility","outpatient",,,"RT","3118","3118",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BX BREAST 1ST LESION STRTCTC LT","30000355","CDM","361","RC","19081","HCPCS",,,"facility","outpatient",,,"LT","6214","6214",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BX BREAST 1ST LESION STRTCTC RT","30000356","CDM","361","RC","19081","HCPCS",,,"facility","outpatient",,,"RT","6214","6214",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PERQ DEVICE BREAST 1ST IMAG BI","30000363","CDM","361","RC","19281","HCPCS",,,"facility","inpatient",,,"50","4502","4502",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PERQ DEVICE BREAST 1ST IMAG BI","30000363","CDM","361","RC","19281","HCPCS",,,"facility","outpatient",,,"50","4502","4502",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PERQ DEVICE BREAST 1ST IMAG LT","30000364","CDM","361","RC","19281","HCPCS",,,"facility","inpatient",,,"LT","3001","3001",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PERQ DEVICE BREAST 1ST IMAG LT","30000364","CDM","361","RC","19281","HCPCS",,,"facility","outpatient",,,"LT","3001","3001",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PERQ DEVICE BREAST 1ST IMAG RT","30000365","CDM","361","RC","19281","HCPCS",,,"facility","inpatient",,,"RT","3001","3001",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PERQ DEVICE BREAST 1ST IMAG RT","30000365","CDM","361","RC","19281","HCPCS",,,"facility","outpatient",,,"RT","3001","3001",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BREAST TOMOSYNTHESIS SCREEN UNILATERAL","30000366","CDM","403","RC","77063","HCPCS",,,"facility","inpatient",,,"52","183","183",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG BREAST TOMOSYNTHESIS SCREEN UNILATERAL","30000366","CDM","403","RC","77063","HCPCS",,,"facility","outpatient",,,"52","183","183",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG XR SPINE SCOLIOSIS 1 VIEW","30000367","CDM","320","RC","72081","HCPCS",,,"facility","inpatient",,,,"575","575",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE SCOLIOSIS 1 VIEW","30000367","CDM","320","RC","72081","HCPCS",,,"facility","outpatient",,,,"575","575",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE SCOLIOSIS 2-3 VIEWS","30000368","CDM","320","RC","72082","HCPCS",,,"facility","inpatient",,,,"820","820",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE SCOLIOSIS 2-3 VIEWS","30000368","CDM","320","RC","72082","HCPCS",,,"facility","outpatient",,,,"820","820",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE SCOLIOSIS 4-5 VIEWS","30000369","CDM","320","RC","72083","HCPCS",,,"facility","inpatient",,,,"972","972",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE SCOLIOSIS 4-5 VIEWS","30000369","CDM","320","RC","72083","HCPCS",,,"facility","outpatient",,,,"972","972",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE SCOLIOSIS MIN 6 VIEWS","30000370","CDM","320","RC","72084","HCPCS",,,"facility","inpatient",,,,"1244","1244",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE SCOLIOSIS MIN 6 VIEWS","30000370","CDM","320","RC","72084","HCPCS",,,"facility","outpatient",,,,"1244","1244",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP UNI W/WO PELVIS 1 VIEW","30000371","CDM","320","RC","73501","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP UNI W/WO PELVIS 1 VIEW","30000371","CDM","320","RC","73501","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP UNI W/WO PELVIS 2-3 VIEWS","30000372","CDM","320","RC","73502","HCPCS",,,"facility","inpatient",,,,"768","768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP UNI W/WO PELVIS 2-3 VIEWS","30000372","CDM","320","RC","73502","HCPCS",,,"facility","outpatient",,,,"768","768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP UNI W/WO PELVIS MIN 4 VIEWS","30000373","CDM","320","RC","73503","HCPCS",,,"facility","inpatient",,,,"1048","1048",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR HIP UNI W/WO PELVIS MIN 4 VIEWS","30000373","CDM","320","RC","73503","HCPCS",,,"facility","outpatient",,,,"1048","1048",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAMMO DX W/WO CAD LT","30000374","CDM","401","RC","77065","HCPCS",,,"facility","inpatient",,,"LT","677","677",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR MAMMO DX W/WO CAD LT","30000374","CDM","401","RC","77065","HCPCS",,,"facility","outpatient",,,"LT","677","677",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR MAMMO DX W/WO CAD BIL","30000375","CDM","401","RC","77066","HCPCS",,,"facility","inpatient",,,,"929","929",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAMMO DX W/WO CAD BIL","30000375","CDM","401","RC","77066","HCPCS",,,"facility","outpatient",,,,"929","929",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAMMO SCREENING W/WO CAD BIL","30000376","CDM","403","RC","77067","HCPCS",,,"facility","inpatient",,,,"602","602",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAMMO SCREENING W/WO CAD BIL","30000376","CDM","403","RC","77067","HCPCS",,,"facility","outpatient",,,,"602","602",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MAMMO SCREENING W/WO CAD UNI","30000377","CDM","403","RC","77067","HCPCS",,,"facility","inpatient",,,"52","401","401",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG XR MAMMO SCREENING W/WO CAD UNI","30000377","CDM","403","RC","77067","HCPCS",,,"facility","outpatient",,,"52","401","401",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG XR MAMMO DX W/WO CAD RT","30000378","CDM","401","RC","77065","HCPCS",,,"facility","inpatient",,,"RT","677","677",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR MAMMO DX W/WO CAD RT","30000378","CDM","401","RC","77065","HCPCS",,,"facility","outpatient",,,"RT","677","677",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR CHEST FRONTAL 1 VIEW","30000383","CDM","324","RC","71045","HCPCS",,,"facility","inpatient",,,,"738","738",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL 1 VIEW","30000383","CDM","324","RC","71045","HCPCS",,,"facility","outpatient",,,,"738","738",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL AND LATERAL 2 VIEW","30000384","CDM","324","RC","71046","HCPCS",,,"facility","inpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL AND LATERAL 2 VIEW","30000384","CDM","324","RC","71046","HCPCS",,,"facility","outpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST SPECIAL VIEWS 2 VIEW","30000385","CDM","324","RC","71046","HCPCS",,,"facility","inpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST SPECIAL VIEWS 2 VIEW","30000385","CDM","324","RC","71046","HCPCS",,,"facility","outpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL AND LATERAL W AP LORDOTIC 3 VW","30000386","CDM","324","RC","71047","HCPCS",,,"facility","inpatient",,,,"723","723",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL AND LATERAL W AP LORDOTIC 3 VW","30000386","CDM","324","RC","71047","HCPCS",,,"facility","outpatient",,,,"723","723",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL AND LATERAL W OBLIQUES 3 VIEW","30000387","CDM","324","RC","71047","HCPCS",,,"facility","inpatient",,,,"723","723",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL AND LATERAL W OBLIQUES 3 VIEW","30000387","CDM","324","RC","71047","HCPCS",,,"facility","outpatient",,,,"723","723",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST SPECIAL VIEWS 3 VIEW","30000388","CDM","324","RC","71047","HCPCS",,,"facility","inpatient",,,,"723","723",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST SPECIAL VIEWS 3 VIEW","30000388","CDM","324","RC","71047","HCPCS",,,"facility","outpatient",,,,"723","723",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL AND LATERAL W OBLIQUES 4+ VIEW","30000389","CDM","324","RC","71048","HCPCS",,,"facility","inpatient",,,,"832","832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST FRONTAL AND LATERAL W OBLIQUES 4+ VIEW","30000389","CDM","324","RC","71048","HCPCS",,,"facility","outpatient",,,,"832","832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST CMPL 4+ VIEW","30000390","CDM","324","RC","71048","HCPCS",,,"facility","inpatient",,,,"832","832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST CMPL 4+ VIEW","30000390","CDM","324","RC","71048","HCPCS",,,"facility","outpatient",,,,"832","832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST SPECIAL VIEWS 4+ VIEW","30000391","CDM","324","RC","71048","HCPCS",,,"facility","inpatient",,,,"832","832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHEST SPECIAL VIEWS 4+ VIEW","30000391","CDM","324","RC","71048","HCPCS",,,"facility","outpatient",,,,"832","832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABD AP 1 VIEW","30000392","CDM","320","RC","74018","HCPCS",,,"facility","inpatient",,,,"666","666",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABD AP 1 VIEW","30000392","CDM","320","RC","74018","HCPCS",,,"facility","outpatient",,,,"666","666",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABD CMPL W DECUB / ERECT 2 VIEW","30000393","CDM","320","RC","74019","HCPCS",,,"facility","inpatient",,,,"921","921",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABD CMPL W DECUB / ERECT 2 VIEW","30000393","CDM","320","RC","74019","HCPCS",,,"facility","outpatient",,,,"921","921",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABD W OBLIQUES AND CONE 3+ VIEW","30000394","CDM","320","RC","74021","HCPCS",,,"facility","inpatient",,,,"879","879",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABD W OBLIQUES AND CONE 3+ VIEW","30000394","CDM","320","RC","74021","HCPCS",,,"facility","outpatient",,,,"879","879",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABD CMPL W DECUB / ERECT 3+ VIEW","30000395","CDM","320","RC","74021","HCPCS",,,"facility","inpatient",,,,"879","879",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ABD CMPL W DECUB / ERECT 3+ VIEW","30000395","CDM","320","RC","74021","HCPCS",,,"facility","outpatient",,,,"879","879",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM STANSON AUC RAD","30000396","CDM","G1010","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM STANSON AUC RAD","30000396","CDM","G1010","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ESOPHAGUS DOUBLE CONTRAST STUDY","30000397","CDM","320","RC","74221","HCPCS",,,"facility","inpatient",,,,"1225","1225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ESOPHAGUS DOUBLE CONTRAST STUDY","30000397","CDM","320","RC","74221","HCPCS",,,"facility","outpatient",,,,"1225","1225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SMALL INTESTINE FOLLOW-THROUGH STUDY","30000398","CDM","320","RC","74248","HCPCS",,,"facility","inpatient",,,,"1149","1149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SMALL INTESTINE FOLLOW-THROUGH STUDY","30000398","CDM","320","RC","74248","HCPCS",,,"facility","outpatient",,,,"1149","1149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TOE(S) 2V OR MORE RT","30000402","CDM","320","RC","73660","HCPCS",,,"facility","inpatient",,,"RT","662","662",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR TOE(S) 2V OR MORE RT","30000402","CDM","320","RC","73660","HCPCS",,,"facility","outpatient",,,"RT","662","662",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CDSM EVICORE AUC RAD","30000403","CDM","G1001","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM EVICORE AUC RAD","30000403","CDM","G1001","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM MEDCURRENT AUC RAD","30000404","CDM","G1002","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM MEDCURRENT AUC RAD","30000404","CDM","G1002","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM MEDICALIS AUC RAD","30000405","CDM","G1003","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM MEDICALIS AUC RAD","30000405","CDM","G1003","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FINGER(S) 2 VIEW OR MORE BI","30000406","CDM","320","RC","73140","HCPCS",,,"facility","inpatient",,,"50","1022","1022",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR FINGER(S) 2 VIEW OR MORE BI","30000406","CDM","320","RC","73140","HCPCS",,,"facility","outpatient",,,"50","1022","1022",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR TOE(S) 2V OR MORE BIL","30000407","CDM","320","RC","73660","HCPCS",,,"facility","inpatient",,,"50","994","994",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG XR TOE(S) 2V OR MORE BIL","30000407","CDM","320","RC","73660","HCPCS",,,"facility","outpatient",,,"50","994","994",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PRQ SACRAL AUG UNI IJ","30000408","CDM","361","RC","0200T","HCPCS",,,"facility","inpatient",,,,"13547","13547",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRQ SACRAL AUG UNI IJ","30000408","CDM","361","RC","0200T","HCPCS",,,"facility","outpatient",,,,"13547","13547",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRQ SACRAL AUG BIL IJ","30000409","CDM","361","RC","0201T","HCPCS",,,"facility","inpatient",,,,"16044","16044",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRQ SACRAL AUG BIL IJ","30000409","CDM","361","RC","0201T","HCPCS",,,"facility","outpatient",,,,"16044","16044",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR RIBS UNI 2V LT","30000413","CDM","320","RC","71100","HCPCS",,,"facility","inpatient",,,"LT","803","803",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR RIBS UNI 2V LT","30000413","CDM","320","RC","71100","HCPCS",,,"facility","outpatient",,,"LT","803","803",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR RIBS UNI 2V RT","30000414","CDM","320","RC","71100","HCPCS",,,"facility","inpatient",,,"RT","803","803",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR RIBS UNI 2V RT","30000414","CDM","320","RC","71100","HCPCS",,,"facility","outpatient",,,"RT","803","803",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR RIBS UNI & PA CHEST LT","30000415","CDM","320","RC","71101","HCPCS",,,"facility","inpatient",,,"LT","1074","1074",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR RIBS UNI & PA CHEST LT","30000415","CDM","320","RC","71101","HCPCS",,,"facility","outpatient",,,"LT","1074","1074",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR RIBS UNI & PA CHEST RT","30000416","CDM","320","RC","71101","HCPCS",,,"facility","inpatient",,,"RT","1074","1074",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR RIBS UNI & PA CHEST RT","30000416","CDM","320","RC","71101","HCPCS",,,"facility","outpatient",,,"RT","1074","1074",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR FINGER(S) 2 VIEW OR MORE RT","30000418","CDM","320","RC","73140","HCPCS",,,"facility","inpatient",,,"RT","681","681",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR FINGER(S) 2 VIEW OR MORE RT","30000418","CDM","320","RC","73140","HCPCS",,,"facility","outpatient",,,"RT","681","681",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PET BRAIN METBLC EVAL","30000430","CDM","404","RC","78608","HCPCS",,,"facility","inpatient",,,,"8792","8792",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET BRAIN METBLC EVAL","30000430","CDM","404","RC","78608","HCPCS",,,"facility","outpatient",,,,"8792","8792",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXCSN BREAST W LOC","30000470","CDM","361","RC","19125","HCPCS",,,"facility","inpatient",,,,"15753","15753",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXCSN BREAST W LOC","30000470","CDM","361","RC","19125","HCPCS",,,"facility","outpatient",,,,"15753","15753",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PV FACET W IMAGE GUIDANCE L/ST 1 LVL BIL","30000488","CDM","361","RC","64493","HCPCS",,,"facility","inpatient",,,"50","7508","7508",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ PV FACET W IMAGE GUIDANCE L/ST 1 LVL BIL","30000488","CDM","361","RC","64493","HCPCS",,,"facility","outpatient",,,"50","7508","7508",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INSERT CATH PLEURA W/ IMAGE","30000490","CDM","361","RC","32557","HCPCS",,,"facility","inpatient",,,,"4102","4102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT CATH PLEURA W/ IMAGE","30000490","CDM","361","RC","32557","HCPCS",,,"facility","outpatient",,,,"4102","4102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM NDSC AUC RAD","30000491","CDM","G1004","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM NDSC AUC RAD","30000491","CDM","G1004","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM AIM AUC RAD","30000494","CDM","G1007","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM AIM AUC RAD","30000494","CDM","G1007","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM CRANBERRY PK AUC RAD","30000495","CDM","G1008","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM CRANBERRY PK AUC RAD","30000495","CDM","G1008","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM SAGE HEALTH AUC RAD","30000496","CDM","G1009","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM QUALIFIED NOS AUC RAD","30000497","CDM","G1011","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM QUALIFIED NOS AUC RAD","30000497","CDM","G1011","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM AGILEMD AUC RAD","30000498","CDM","G1012","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM AGILEMD AUC RAD","30000498","CDM","G1012","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM EVIDENCECARE AUC RAD","30000499","CDM","G1013","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM EVIDENCECARE AUC RAD","30000499","CDM","G1013","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM INVENIQA AUC RAD","30000500","CDM","G1014","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM INVENIQA AUC RAD","30000500","CDM","G1014","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM RELIANT AUC RAD","30000501","CDM","G1015","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM RELIANT AUC RAD","30000501","CDM","G1015","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM SPEED OF CARE AUC RAD","30000502","CDM","G1016","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM SPEED OF CARE AUC RAD","30000502","CDM","G1016","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM HEALTHHELP AUC RAD","30000503","CDM","G1017","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM HEALTHHELP AUC RAD","30000503","CDM","G1017","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM INFINX AUC RAD","30000504","CDM","G1018","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM INFINX AUC RAD","30000504","CDM","G1018","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM LOGICNETS AUC RAD","30000505","CDM","G1019","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM LOGICNETS AUC RAD","30000505","CDM","G1019","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM CURBSIDE AUC RAD","30000512","CDM","G1020","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM CURBSIDE AUC RAD","30000512","CDM","G1020","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM EHEALTHLINE AUC RAD","30000513","CDM","G1021","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM EHEALTHLINE AUC RAD","30000513","CDM","G1021","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM INTERMOUNTAIN AUC RAD","30000514","CDM","G1022","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM INTERMOUNTAIN AUC RAD","30000514","CDM","G1022","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM PERSIVIA AUC RAD","30000515","CDM","G1023","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM PERSIVIA AUC RAD","30000515","CDM","G1023","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM RADRITE AUC RAD","30000516","CDM","G1024","HCPCS",,,,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CDSM RADRITE AUC RAD","30000516","CDM","G1024","HCPCS",,,,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST 1ST LESION STRTCTC","30000517","CDM","361","RC","19081","HCPCS",,,"facility","inpatient",,,,"6214","6214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST 1ST LESION STRTCTC","30000517","CDM","361","RC","19081","HCPCS",,,"facility","outpatient",,,,"6214","6214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST ADD LESION STRTCTC","30000518","CDM","361","RC","19082","HCPCS",,,"facility","inpatient",,,,"3976","3976",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST ADD LESION STRTCTC","30000518","CDM","361","RC","19082","HCPCS",,,"facility","outpatient",,,,"3976","3976",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST 1ST LESION US IMAG","30000519","CDM","361","RC","19083","HCPCS",,,"facility","inpatient",,,,"5467","5467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST 1ST LESION US IMAG","30000519","CDM","361","RC","19083","HCPCS",,,"facility","outpatient",,,,"5467","5467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST ADD LESION US IMAG","30000520","CDM","361","RC","19084","HCPCS",,,"facility","inpatient",,,,"3118","3118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST ADD LESION US IMAG","30000520","CDM","361","RC","19084","HCPCS",,,"facility","outpatient",,,,"3118","3118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST 1ST LESION MR IMAG","30000521","CDM","361","RC","19085","HCPCS",,,"facility","inpatient",,,,"6797","6797",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST 1ST LESION MR IMAG","30000521","CDM","361","RC","19085","HCPCS",,,"facility","outpatient",,,,"6797","6797",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST ADD LESION MR IMAG","30000522","CDM","361","RC","19086","HCPCS",,,"facility","inpatient",,,,"4436","4436",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST ADD LESION MR IMAG","30000522","CDM","361","RC","19086","HCPCS",,,"facility","outpatient",,,,"4436","4436",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CISTERNOGRAM","30045000","CDM","320","RC","70015","HCPCS",,,"facility","inpatient",,,,"3620","3620",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CISTERNOGRAM","30045000","CDM","320","RC","70015","HCPCS",,,"facility","outpatient",,,,"3620","3620",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MYELOGRAM CERV","30045002","CDM","320","RC","72240","HCPCS",,,"facility","inpatient",,,,"2690","2690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MYELOGRAM CERV","30045002","CDM","320","RC","72240","HCPCS",,,"facility","outpatient",,,,"2690","2690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MYELOGRAM LUMB","30045003","CDM","320","RC","72265","HCPCS",,,"facility","inpatient",,,,"4112","4112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR MYELOGRAM LUMB","30045003","CDM","320","RC","72265","HCPCS",,,"facility","outpatient",,,,"4112","4112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EPIDUROGRAM","30045005","CDM","320","RC","72275","HCPCS",,,"facility","outpatient",,,,"542","542",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DISCOGRAM CERV AND THOR","30045006","CDM","320","RC","72285","HCPCS",,,"facility","inpatient",,,,"2982","2982",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DISCOGRAM CERV AND THOR","30045006","CDM","320","RC","72285","HCPCS",,,"facility","outpatient",,,,"2982","2982",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DISCOGRAM LUMB","30045008","CDM","320","RC","72295","HCPCS",,,"facility","inpatient",,,,"2378","2378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DISCOGRAM LUMB","30045008","CDM","320","RC","72295","HCPCS",,,"facility","outpatient",,,,"2378","2378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ARTHRO KNEE LT","30045018","CDM","322","RC","73580","HCPCS",,,"facility","inpatient",,,"LT","1892","1892",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG IR ARTHRO KNEE LT","30045018","CDM","322","RC","73580","HCPCS",,,"facility","outpatient",,,"LT","1892","1892",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG IR ARTHRO KNEE RT","30045019","CDM","322","RC","73580","HCPCS",,,"facility","inpatient",,,"RT","1892","1892",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG IR ARTHRO KNEE RT","30045019","CDM","322","RC","73580","HCPCS",,,"facility","outpatient",,,"RT","1892","1892",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG FB RMV ESOPHAGUS","30045020","CDM","320","RC","74235","HCPCS",,,"facility","inpatient",,,,"3663","3663",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FB RMV ESOPHAGUS","30045020","CDM","320","RC","74235","HCPCS",,,"facility","outpatient",,,,"3663","3663",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ENDO BILI DUCT","30045024","CDM","320","RC","74328","HCPCS",,,"facility","inpatient",,,,"2986","2986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ENDO BILI DUCT","30045024","CDM","320","RC","74328","HCPCS",,,"facility","outpatient",,,,"2986","2986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ERCP PANC DUCT","30045025","CDM","320","RC","74329","HCPCS",,,"facility","inpatient",,,,"3291","3291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ERCP PANC DUCT","30045025","CDM","320","RC","74329","HCPCS",,,"facility","outpatient",,,,"3291","3291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ERCP BILI PANC DUCT","30045026","CDM","320","RC","74330","HCPCS",,,"facility","inpatient",,,,"3008","3008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR ERCP BILI PANC DUCT","30045026","CDM","320","RC","74330","HCPCS",,,"facility","outpatient",,,,"3008","3008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR INTRALUMINAL DILATION","30045030","CDM","320","RC","74360","HCPCS",,,"facility","inpatient",,,,"1027","1027",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR INTRALUMINAL DILATION","30045030","CDM","320","RC","74360","HCPCS",,,"facility","outpatient",,,,"1027","1027",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BILI DUCT DILATE PERC","30045031","CDM","320","RC","74363","HCPCS",,,"facility","inpatient",,,,"3417","3417",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR BILI DUCT DILATE PERC","30045031","CDM","320","RC","74363","HCPCS",,,"facility","outpatient",,,,"3417","3417",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH INTRACRANIAL ART","30045034","CDM","361","RC","36228","HCPCS",,,"facility","inpatient",,,,"12590","12590",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH INTRACRANIAL ART","30045034","CDM","361","RC","36228","HCPCS",,,"facility","outpatient",,,,"12590","12590",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH XTRNL CAROTID","30045035","CDM","361","RC","36227","HCPCS",,,"facility","inpatient",,,,"19378","19378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH XTRNL CAROTID","30045035","CDM","361","RC","36227","HCPCS",,,"facility","outpatient",,,,"19378","19378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CORPORA CAVERNOSOGRAM","30045036","CDM","320","RC","74445","HCPCS",,,"facility","inpatient",,,,"1447","1447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CORPORA CAVERNOSOGRAM","30045036","CDM","320","RC","74445","HCPCS",,,"facility","outpatient",,,,"1447","1447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH VERTEBRAL ART","30045038","CDM","361","RC","36226","HCPCS",,,"facility","inpatient",,,,"26571","26571",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH VERTEBRAL ART","30045038","CDM","361","RC","36226","HCPCS",,,"facility","outpatient",,,,"26571","26571",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH SUBCLAVIAN ART","30045039","CDM","361","RC","36225","HCPCS",,,"facility","inpatient",,,,"17249","17249",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH SUBCLAVIAN ART","30045039","CDM","361","RC","36225","HCPCS",,,"facility","outpatient",,,,"17249","17249",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH CAROTD ART","30045040","CDM","361","RC","36224","HCPCS",,,"facility","inpatient",,,,"25251","25251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH CAROTD ART","30045040","CDM","361","RC","36224","HCPCS",,,"facility","outpatient",,,,"25251","25251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DILATION URETHRA OR URETER S&I","30045041","CDM","320","RC","74485","HCPCS",,,"facility","inpatient",,,,"4933","4933",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DILATION URETHRA OR URETER S&I","30045041","CDM","320","RC","74485","HCPCS",,,"facility","outpatient",,,,"4933","4933",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR AORTOGRAM THOR WO SERIALOGRAPHY","30045044","CDM","323","RC","75600","HCPCS",,,"facility","inpatient",,,,"5504","5504",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR AORTOGRAM THOR WO SERIALOGRAPHY","30045044","CDM","323","RC","75600","HCPCS",,,"facility","outpatient",,,,"5504","5504",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR AORTOGRAM THOR W SERIALOGRAPHY","30045045","CDM","323","RC","75605","HCPCS",,,"facility","inpatient",,,,"10840","10840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR AORTOGRAM THOR W SERIALOGRAPHY","30045045","CDM","323","RC","75605","HCPCS",,,"facility","outpatient",,,,"10840","10840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR AORTOGRAM ABD W SERIALOGRAPHY","30045046","CDM","323","RC","75625","HCPCS",,,"facility","inpatient",,,,"10950","10950",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR AORTOGRAM ABD W SERIALOGRAPHY","30045046","CDM","323","RC","75625","HCPCS",,,"facility","outpatient",,,,"10950","10950",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR AORTOGRAM ABD W BILAT LOWER EXTREM","30045047","CDM","323","RC","75630","HCPCS",,,"facility","inpatient",,,,"12702","12702",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR AORTOGRAM ABD W BILAT LOWER EXTREM","30045047","CDM","323","RC","75630","HCPCS",,,"facility","outpatient",,,,"12702","12702",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO SPINAL SELECT","30045057","CDM","323","RC","75705","HCPCS",,,"facility","inpatient",,,,"12782","12782",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO SPINAL SELECT","30045057","CDM","323","RC","75705","HCPCS",,,"facility","outpatient",,,,"12782","12782",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO EXTREM BILAT","30045059","CDM","323","RC","75716","HCPCS",,,"facility","inpatient",,,,"11739","11739",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO EXTREM BILAT","30045059","CDM","323","RC","75716","HCPCS",,,"facility","outpatient",,,,"11739","11739",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO VISCERAL","30045062","CDM","323","RC","75726","HCPCS",,,"facility","inpatient",,,,"13544","13544",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO VISCERAL","30045062","CDM","323","RC","75726","HCPCS",,,"facility","outpatient",,,,"13544","13544",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO ADRENAL BILAT","30045064","CDM","323","RC","75733","HCPCS",,,"facility","inpatient",,,,"7500","7500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO ADRENAL BILAT","30045064","CDM","323","RC","75733","HCPCS",,,"facility","outpatient",,,,"7500","7500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO PELVIC SELECT","30045065","CDM","323","RC","75736","HCPCS",,,"facility","inpatient",,,,"14417","14417",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO PELVIC SELECT","30045065","CDM","323","RC","75736","HCPCS",,,"facility","outpatient",,,,"14417","14417",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO PULM BILAT SELECT","30045067","CDM","323","RC","75743","HCPCS",,,"facility","inpatient",,,,"8381","8381",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO PULM BILAT SELECT","30045067","CDM","323","RC","75743","HCPCS",,,"facility","outpatient",,,,"8381","8381",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO PULM NON SELECT","30045068","CDM","323","RC","75746","HCPCS",,,"facility","inpatient",,,,"4675","4675",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO PULM NON SELECT","30045068","CDM","323","RC","75746","HCPCS",,,"facility","outpatient",,,,"4675","4675",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO INT MAMMARY","30045069","CDM","323","RC","75756","HCPCS",,,"facility","inpatient",,,,"9292","9292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO INT MAMMARY","30045069","CDM","323","RC","75756","HCPCS",,,"facility","outpatient",,,,"9292","9292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO EA ADDL VESSEL AFTER BASIC EXAM","30045070","CDM","323","RC","75774","HCPCS",,,"facility","inpatient",,,,"6201","6201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO EA ADDL VESSEL AFTER BASIC EXAM","30045070","CDM","323","RC","75774","HCPCS",,,"facility","outpatient",,,,"6201","6201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPLENOPORTOGRAM","30045072","CDM","320","RC","75810","HCPCS",,,"facility","inpatient",,,,"15572","15572",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPLENOPORTOGRAM","30045072","CDM","320","RC","75810","HCPCS",,,"facility","outpatient",,,,"15572","15572",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM EXTREM BILAT","30045074","CDM","320","RC","75822","HCPCS",,,"facility","inpatient",,,,"4966","4966",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM EXTREM BILAT","30045074","CDM","320","RC","75822","HCPCS",,,"facility","outpatient",,,,"4966","4966",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM IVC","30045075","CDM","320","RC","75825","HCPCS",,,"facility","inpatient",,,,"9070","9070",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM IVC","30045075","CDM","320","RC","75825","HCPCS",,,"facility","outpatient",,,,"9070","9070",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM SVC","30045076","CDM","320","RC","75827","HCPCS",,,"facility","inpatient",,,,"5360","5360",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM SVC","30045076","CDM","320","RC","75827","HCPCS",,,"facility","outpatient",,,,"5360","5360",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM RENAL BILAT","30045078","CDM","320","RC","75833","HCPCS",,,"facility","inpatient",,,,"6237","6237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM RENAL BILAT","30045078","CDM","320","RC","75833","HCPCS",,,"facility","outpatient",,,,"6237","6237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM ADRENAL BILAT","30045080","CDM","320","RC","75842","HCPCS",,,"facility","inpatient",,,,"5056","5056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM ADRENAL BILAT","30045080","CDM","320","RC","75842","HCPCS",,,"facility","outpatient",,,,"5056","5056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM SINUS JUGULAR","30045081","CDM","320","RC","75860","HCPCS",,,"facility","inpatient",,,,"6866","6866",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM SINUS JUGULAR","30045081","CDM","320","RC","75860","HCPCS",,,"facility","outpatient",,,,"6866","6866",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM SAG SINUS","30045082","CDM","320","RC","75870","HCPCS",,,"facility","inpatient",,,,"2817","2817",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM SAG SINUS","30045082","CDM","320","RC","75870","HCPCS",,,"facility","outpatient",,,,"2817","2817",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM EPIDURAL","30045083","CDM","320","RC","75872","HCPCS",,,"facility","inpatient",,,,"6073","6073",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM EPIDURAL","30045083","CDM","320","RC","75872","HCPCS",,,"facility","outpatient",,,,"6073","6073",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM ORBITAL","30045084","CDM","320","RC","75880","HCPCS",,,"facility","inpatient",,,,"2605","2605",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM ORBITAL","30045084","CDM","320","RC","75880","HCPCS",,,"facility","outpatient",,,,"2605","2605",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PORTOGRAM W HEMO EVAL","30045085","CDM","320","RC","75885","HCPCS",,,"facility","inpatient",,,,"5953","5953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PORTOGRAM W HEMO EVAL","30045085","CDM","320","RC","75885","HCPCS",,,"facility","outpatient",,,,"5953","5953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PORTOGRAM WO HEMO EVAL","30045086","CDM","320","RC","75887","HCPCS",,,"facility","inpatient",,,,"4986","4986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PORTOGRAM WO HEMO EVAL","30045086","CDM","320","RC","75887","HCPCS",,,"facility","outpatient",,,,"4986","4986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM HEP W HEMO EVAL","30045087","CDM","320","RC","75889","HCPCS",,,"facility","inpatient",,,,"10261","10261",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM HEP W HEMO EVAL","30045087","CDM","320","RC","75889","HCPCS",,,"facility","outpatient",,,,"10261","10261",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM HEP WO HEMO EVAL","30045088","CDM","320","RC","75891","HCPCS",,,"facility","inpatient",,,,"14768","14768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR VENOGRAM HEP WO HEMO EVAL","30045088","CDM","320","RC","75891","HCPCS",,,"facility","outpatient",,,,"14768","14768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENOUS SAMPLING","30045089","CDM","320","RC","75893","HCPCS",,,"facility","inpatient",,,,"9044","9044",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENOUS SAMPLING","30045089","CDM","320","RC","75893","HCPCS",,,"facility","outpatient",,,,"9044","9044",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR EMBOL TRANSCATH","30045090","CDM","320","RC","75894","HCPCS",,,"facility","inpatient",,,,"15840","15840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR EMBOL TRANSCATH","30045090","CDM","320","RC","75894","HCPCS",,,"facility","outpatient",,,,"15840","15840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANGIOGRAPHY CATH F/U TRANSCATH TX NO THROMBYLSIS","30045092","CDM","323","RC","75898","HCPCS",,,"facility","inpatient",,,,"6169","6169",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANGIOGRAPHY CATH F/U TRANSCATH TX NO THROMBYLSIS","30045092","CDM","323","RC","75898","HCPCS",,,"facility","outpatient",,,,"6169","6169",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR THORACIC AA ENDOVASCULAR PROSTHESIS PLACEMENT WITH SUBCLAVIAN","30045100","CDM","320","RC","75956","HCPCS",,,"facility","inpatient",,,,"2022","2022",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR THORACIC AA ENDOVASCULAR PROSTHESIS PLACEMENT WITH SUBCLAVIAN","30045100","CDM","320","RC","75956","HCPCS",,,"facility","outpatient",,,,"2022","2022",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR THORACIC AA ENDOVASCULAR PROSTHESIS REPAIR WITHOUT SUBCLAVIAN","30045101","CDM","320","RC","75957","HCPCS",,,"facility","inpatient",,,,"1805","1805",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR THORACIC AA ENDOVASCULAR PROSTHESIS REPAIR WITHOUT SUBCLAVIAN","30045101","CDM","320","RC","75957","HCPCS",,,"facility","outpatient",,,,"1805","1805",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR THORACIC AA DESCENDING ENDOVASCULAR PROSTHESIS PLACEMENT","30045102","CDM","320","RC","75958","HCPCS",,,"facility","inpatient",,,,"2503","2503",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR THORACIC AA DESCENDING ENDOVASCULAR PROSTHESIS PLACEMENT","30045102","CDM","320","RC","75958","HCPCS",,,"facility","outpatient",,,,"2503","2503",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR THORACIC AA DESCENDING ENDOVASCULAR PLACEMENT PROSTHESIS FOR ENDOLEAK","30045103","CDM","320","RC","75959","HCPCS",,,"facility","inpatient",,,,"1047","1047",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR THORACIC AA DESCENDING ENDOVASCULAR PLACEMENT PROSTHESIS FOR ENDOLEAK","30045103","CDM","320","RC","75959","HCPCS",,,"facility","outpatient",,,,"1047","1047",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX TRANSCATHETER","30045110","CDM","320","RC","75970","HCPCS",,,"facility","inpatient",,,,"6257","6257",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX TRANSCATHETER","30045110","CDM","320","RC","75970","HCPCS",,,"facility","outpatient",,,,"6257","6257",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHANGE PERC TUBE/DRAINAGE CATH W CONTR MON","30045114","CDM","320","RC","75984","HCPCS",,,"facility","inpatient",,,,"2997","2997",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CHANGE PERC TUBE/DRAINAGE CATH W CONTR MON","30045114","CDM","320","RC","75984","HCPCS",,,"facility","outpatient",,,,"2997","2997",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DRAINAGE W CATH PLACEMENT PERC","30045115","CDM","320","RC","75989","HCPCS",,,"facility","inpatient",,,,"3144","3144",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR DRAINAGE W CATH PLACEMENT PERC","30045115","CDM","320","RC","75989","HCPCS",,,"facility","outpatient",,,,"3144","3144",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORO 1 HR OR LESS","30045121","CDM","320","RC","76000","HCPCS",,,"facility","inpatient",,,,"1733","1733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORO 1 HR OR LESS","30045121","CDM","320","RC","76000","HCPCS",,,"facility","outpatient",,,,"1733","1733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CATH CAROTID/INOM ART XCA","30045123","CDM","361","RC","36223","HCPCS",,,"facility","inpatient",,,,"26947","26947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CATH CAROTID/INOM ART XCA","30045123","CDM","361","RC","36223","HCPCS",,,"facility","outpatient",,,,"26947","26947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CATH CAROTID/INOM ART CA","30045124","CDM","361","RC","36222","HCPCS",,,"facility","inpatient",,,,"19608","19608",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CATH CAROTID/INOM ART CA","30045124","CDM","361","RC","36222","HCPCS",,,"facility","outpatient",,,,"19608","19608",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR 3D RENDERING INTERP&POSTPROC DIF WORK STATION","30045125","CDM","320","RC","76377","HCPCS",,,"facility","inpatient",,,,"2034","2034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR 3D RENDERING INTERP&POSTPROC DIF WORK STATION","30045125","CDM","320","RC","76377","HCPCS",,,"facility","outpatient",,,,"2034","2034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH THORACIC AORTA","30045126","CDM","361","RC","36221","HCPCS",,,"facility","inpatient",,,,"15070","15070",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE CATH THORACIC AORTA","30045126","CDM","361","RC","36221","HCPCS",,,"facility","outpatient",,,,"15070","15070",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE INTRVAS FOREIGN BODY","30045127","CDM","361","RC","37197","HCPCS",,,"facility","inpatient",,,,"14944","14944",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE INTRVAS FOREIGN BODY","30045127","CDM","361","RC","37197","HCPCS",,,"facility","outpatient",,,,"14944","14944",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORO CVC PLACE REPLACE REMOVE","30045128","CDM","320","RC","77001","HCPCS",,,"facility","inpatient",,,,"2084","2084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORO CVC PLACE REPLACE REMOVE","30045128","CDM","320","RC","77001","HCPCS",,,"facility","outpatient",,,,"2084","2084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FLUORO NDL PLACE","30045129","CDM","320","RC","77002","HCPCS",,,"facility","inpatient",,,,"1640","1640",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR FLUORO NDL PLACE","30045129","CDM","320","RC","77002","HCPCS",,,"facility","outpatient",,,,"1640","1640",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORO GUIDE/LOC NDL/CATH TIP SPINE/THERPTC INJ","30045130","CDM","320","RC","77003","HCPCS",,,"facility","inpatient",,,,"1476","1476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORO GUIDE/LOC NDL/CATH TIP SPINE/THERPTC INJ","30045130","CDM","320","RC","77003","HCPCS",,,"facility","outpatient",,,,"1476","1476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PERITONEOGRAM","30045135","CDM","320","RC","74190","HCPCS",,,"facility","inpatient",,,,"1026","1026",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR PERITONEOGRAM","30045135","CDM","320","RC","74190","HCPCS",,,"facility","outpatient",,,,"1026","1026",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR LYMPHANGIOGRAM EXT UNILATERAL RT","30045137","CDM","320","RC","75801","HCPCS",,,"facility","inpatient",,,"RT","9693","9693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR LYMPHANGIOGRAM EXT UNILATERAL RT","30045137","CDM","320","RC","75801","HCPCS",,,"facility","outpatient",,,"RT","9693","9693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR LYMPHANGIOGRAM ABD UNILATERAL LT","30045139","CDM","320","RC","75805","HCPCS",,,"facility","inpatient",,,"LT","4723","4723",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR LYMPHANGIOGRAM ABD UNILATERAL LT","30045139","CDM","320","RC","75805","HCPCS",,,"facility","outpatient",,,"LT","4723","4723",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR LYMPHANGIOGRAM ABD UNILATERAL RT","30045140","CDM","320","RC","75805","HCPCS",,,"facility","inpatient",,,"RT","4723","4723",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR LYMPHANGIOGRAM ABD UNILATERAL RT","30045140","CDM","320","RC","75805","HCPCS",,,"facility","outpatient",,,"RT","4723","4723",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR SHUNTOGRAM NONVASC","30045142","CDM","320","RC","75809","HCPCS",,,"facility","inpatient",,,,"927","927",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SHUNTOGRAM NONVASC","30045142","CDM","320","RC","75809","HCPCS",,,"facility","outpatient",,,,"927","927",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CINE/VIDEO COMPLEMENT","30045143","CDM","320","RC","76125","HCPCS",,,"facility","inpatient",,,,"915","915",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CINE/VIDEO COMPLEMENT","30045143","CDM","320","RC","76125","HCPCS",,,"facility","outpatient",,,,"915","915",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TUBE THORACOSTOMY","30045146","CDM","361","RC","32551","HCPCS",,,"facility","inpatient",,,,"3854","3854",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TUBE THORACOSTOMY","30045146","CDM","361","RC","32551","HCPCS",,,"facility","outpatient",,,,"3854","3854",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UGI ENDO W GASTROSTOMY TUBE PLACEMENT","30045148","CDM","361","RC","43246","HCPCS",,,"facility","inpatient",,,,"7757","7757",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UGI ENDO W GASTROSTOMY TUBE PLACEMENT","30045148","CDM","361","RC","43246","HCPCS",,,"facility","outpatient",,,,"7757","7757",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THORACENTESIS WO IMAGING","30045151","CDM","361","RC","32554","HCPCS",,,"facility","inpatient",,,,"3229","3229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THORACENTESIS WO IMAGING","30045151","CDM","361","RC","32554","HCPCS",,,"facility","outpatient",,,,"3229","3229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CESSJ THERAPY CATH REMOVAL","30045152","CDM","361","RC","37214","HCPCS",,,"facility","inpatient",,,,"11652","11652",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CESSJ THERAPY CATH REMOVAL","30045152","CDM","361","RC","37214","HCPCS",,,"facility","outpatient",,,,"11652","11652",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO CNS W/SPINAL PUNCTURE","30045153","CDM","331","RC","96450","HCPCS",,,"facility","inpatient",,,,"2007","2007",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO CNS W/SPINAL PUNCTURE","30045153","CDM","331","RC","96450","HCPCS",,,"facility","outpatient",,,,"2007","2007",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE G TUBE PERC","30045154","CDM","361","RC","49440","HCPCS",,,"facility","inpatient",,,,"4876","4876",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE G TUBE PERC","30045154","CDM","361","RC","49440","HCPCS",,,"facility","outpatient",,,,"4876","4876",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHANGE G-TUBE TO G-J PRC","30045155","CDM","361","RC","49446","HCPCS",,,"facility","inpatient",,,,"6090","6090",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHANGE G-TUBE TO G-J PRC","30045155","CDM","361","RC","49446","HCPCS",,,"facility","outpatient",,,,"6090","6090",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE LUNG CATHETER","30045156","CDM","361","RC","32552","HCPCS",,,"facility","inpatient",,,,"4086","4086",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE LUNG CATHETER","30045156","CDM","361","RC","32552","HCPCS",,,"facility","outpatient",,,,"4086","4086",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSTILLATION ID RT THOR PERC","30045157","CDM","361","RC","32553","HCPCS",,,"facility","inpatient",,,,"5138","5138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSTILLATION ID RT THOR PERC","30045157","CDM","361","RC","32553","HCPCS",,,"facility","outpatient",,,,"5138","5138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSTILLATION PLRO AGT INTL DAY","30045158","CDM","361","RC","32561","HCPCS",,,"facility","inpatient",,,,"3441","3441",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSTILLATION PLRO AGT INTL DAY","30045158","CDM","361","RC","32561","HCPCS",,,"facility","outpatient",,,,"3441","3441",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSTILLATION PLRO AGT SUBQ DAY","30045159","CDM","361","RC","32562","HCPCS",,,"facility","inpatient",,,,"611","611",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSTILLATION PLRO AGT SUBQ DAY","30045159","CDM","361","RC","32562","HCPCS",,,"facility","outpatient",,,,"611","611",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBLYTIC ART/VEN THERAPY","30045165","CDM","361","RC","37213","HCPCS",,,"facility","inpatient",,,,"17273","17273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBLYTIC ART/VEN THERAPY","30045165","CDM","361","RC","37213","HCPCS",,,"facility","outpatient",,,,"17273","17273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBOLYTIC VENOUS THERAPY","30045166","CDM","361","RC","37212","HCPCS",,,"facility","inpatient",,,,"7891","7891",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBOLYTIC VENOUS THERAPY","30045166","CDM","361","RC","37212","HCPCS",,,"facility","outpatient",,,,"7891","7891",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBOLYTIC ART THERAPY","30045167","CDM","361","RC","37211","HCPCS",,,"facility","inpatient",,,,"16785","16785",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBOLYTIC ART THERAPY","30045167","CDM","361","RC","37211","HCPCS",,,"facility","outpatient",,,,"16785","16785",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVASC W/TLA","30045170","CDM","361","RC","37228","HCPCS",,,"facility","inpatient",,,,"27954","27954",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVASC W/TLA","30045170","CDM","361","RC","37228","HCPCS",,,"facility","outpatient",,,,"27954","27954",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVASC W/ATHR","30045172","CDM","361","RC","37229","HCPCS",,,"facility","inpatient",,,,"47354","47354",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVASC W/ATHR","30045172","CDM","361","RC","37229","HCPCS",,,"facility","outpatient",,,,"47354","47354",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVASC W/STNT","30045173","CDM","361","RC","37230","HCPCS",,,"facility","inpatient",,,,"43291","43291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVASC W/STNT","30045173","CDM","361","RC","37230","HCPCS",,,"facility","outpatient",,,,"43291","43291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVAS ST/ATHR","30045174","CDM","361","RC","37231","HCPCS",,,"facility","inpatient",,,,"58195","58195",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVAS ST/ATHR","30045174","CDM","361","RC","37231","HCPCS",,,"facility","outpatient",,,,"58195","58195",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVASC ADD-ON","30045175","CDM","361","RC","37232","HCPCS",,,"facility","inpatient",,,,"16065","16065",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIB/PER REVASC ADD-ON","30045175","CDM","361","RC","37232","HCPCS",,,"facility","outpatient",,,,"16065","16065",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TB/PR REVS W/ATHR ADD","30045176","CDM","361","RC","37233","HCPCS",,,"facility","inpatient",,,,"23075","23075",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TB/PR REVS W/ATHR ADD","30045176","CDM","361","RC","37233","HCPCS",,,"facility","outpatient",,,,"23075","23075",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TB/PR OP/PR REVS STNT","30045177","CDM","361","RC","37234","HCPCS",,,"facility","inpatient",,,,"30250","30250",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TB/PR OP/PR REVS STNT","30045177","CDM","361","RC","37234","HCPCS",,,"facility","outpatient",,,,"30250","30250",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FEM/POPL REVAS W/TLA","30045179","CDM","361","RC","37224","HCPCS",,,"facility","inpatient",,,,"26364","26364",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FEM/POPL REVAS W/TLA","30045179","CDM","361","RC","37224","HCPCS",,,"facility","outpatient",,,,"26364","26364",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FEM/POPL REVAS W/ATHR","30045180","CDM","361","RC","37225","HCPCS",,,"facility","inpatient",,,,"38360","38360",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FEM/POPL REVAS W/ATHR","30045180","CDM","361","RC","37225","HCPCS",,,"facility","outpatient",,,,"38360","38360",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FEM/POPL REVAS W/STNT","30045181","CDM","361","RC","37226","HCPCS",,,"facility","inpatient",,,,"39799","39799",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FEM/POPL REVAS W/STNT","30045181","CDM","361","RC","37226","HCPCS",,,"facility","outpatient",,,,"39799","39799",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FEM/POP REVSC ST/ATHR","30045182","CDM","361","RC","37227","HCPCS",,,"facility","inpatient",,,,"53408","53408",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FEM/POP REVSC ST/ATHR","30045182","CDM","361","RC","37227","HCPCS",,,"facility","outpatient",,,,"53408","53408",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ILIAC REVASC ADD-ON","30045185","CDM","361","RC","37222","HCPCS",,,"facility","inpatient",,,,"18637","18637",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ILIAC REVASC ADD-ON","30045185","CDM","361","RC","37222","HCPCS",,,"facility","outpatient",,,,"18637","18637",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ILIAC REVS W/STNT ADD","30045186","CDM","361","RC","37223","HCPCS",,,"facility","inpatient",,,,"20948","20948",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ILIAC REVS W/STNT ADD","30045186","CDM","361","RC","37223","HCPCS",,,"facility","outpatient",,,,"20948","20948",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GUIDE CATHET FLUID DRAINAGE","30045187","CDM","361","RC","10030","HCPCS",,,"facility","inpatient",,,,"3210","3210",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GUIDE CATHET FLUID DRAINAGE","30045187","CDM","361","RC","10030","HCPCS",,,"facility","outpatient",,,,"3210","3210",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PR ATHR BRCHIOCPH","30045188","CDM","361","RC","0237T","HCPCS",,,"facility","inpatient",,,,"70291","70291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PR ATHR BRCHIOCPH","30045188","CDM","361","RC","0237T","HCPCS",,,"facility","outpatient",,,,"70291","70291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PER ATHR RENAL AR","30045190","CDM","361","RC","0234T","HCPCS",,,"facility","inpatient",,,,"68899","68899",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PER ATHR RENAL AR","30045190","CDM","361","RC","0234T","HCPCS",,,"facility","outpatient",,,,"68899","68899",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PER ATHR VISCERAL","30045192","CDM","361","RC","0235T","HCPCS",,,"facility","inpatient",,,,"68899","68899",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PER ATHR VISCERAL","30045192","CDM","361","RC","0235T","HCPCS",,,"facility","outpatient",,,,"68899","68899",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASC VISC AORTA 2 GRAFT","30045193","CDM","361","RC","34842","HCPCS",,,"facility","inpatient",,,,"7149","7149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASC VISC AORTA 2 GRAFT","30045193","CDM","361","RC","34842","HCPCS",,,"facility","outpatient",,,,"7149","7149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PR ATHR ILIAC ART","30045196","CDM","361","RC","0238T","HCPCS",,,"facility","inpatient",,,,"40084","40084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PR ATHR ILIAC ART","30045196","CDM","361","RC","0238T","HCPCS",,,"facility","outpatient",,,,"40084","40084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PR ATHR ABD AORTA","30045202","CDM","361","RC","0236T","HCPCS",,,"facility","inpatient",,,,"72387","72387",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRL PR ATHR ABD AORTA","30045202","CDM","361","RC","0236T","HCPCS",,,"facility","outpatient",,,,"72387","72387",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN/PERQ PLACE STENT 1ST","30045204","CDM","361","RC","37236","HCPCS",,,"facility","inpatient",,,,"34023","34023",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN/PERQ PLACE STENT 1ST","30045204","CDM","361","RC","37236","HCPCS",,,"facility","outpatient",,,,"34023","34023",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN/PERQ PLACE STENT EA ADD ART","30045207","CDM","361","RC","37237","HCPCS",,,"facility","inpatient",,,,"26810","26810",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN/PERQ PLACE STENT EA ADD ART","30045207","CDM","361","RC","37237","HCPCS",,,"facility","outpatient",,,,"26810","26810",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN/PERQ PLACE STENT SAME","30045208","CDM","361","RC","37238","HCPCS",,,"facility","inpatient",,,,"34230","34230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN/PERQ PLACE STENT SAME","30045208","CDM","361","RC","37238","HCPCS",,,"facility","outpatient",,,,"34230","34230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN/PERQ PLACE STENT EA ADD VEIN","30045209","CDM","361","RC","37239","HCPCS",,,"facility","inpatient",,,,"19057","19057",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPEN/PERQ PLACE STENT EA ADD VEIN","30045209","CDM","361","RC","37239","HCPCS",,,"facility","outpatient",,,,"19057","19057",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASC EMBOLIZE/OCCLUDE VENOUS","30045212","CDM","361","RC","37241","HCPCS",,,"facility","inpatient",,,,"33841","33841",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASC EMBOLIZE/OCCLUDE VENOUS","30045212","CDM","361","RC","37241","HCPCS",,,"facility","outpatient",,,,"33841","33841",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASC EMBOLIZE/OCCLUDE ARTERY","30045213","CDM","361","RC","37242","HCPCS",,,"facility","inpatient",,,,"33254","33254",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASC EMBOLIZE/OCCLUDE ARTERY","30045213","CDM","361","RC","37242","HCPCS",,,"facility","outpatient",,,,"33254","33254",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASC EMBOLIZE/OCCLUDE ORGAN","30045214","CDM","361","RC","37243","HCPCS",,,"facility","inpatient",,,,"32641","32641",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASC EMBOLIZE/OCCLUDE ORGAN","30045214","CDM","361","RC","37243","HCPCS",,,"facility","outpatient",,,,"32641","32641",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSR TUN IP CATH PERC","30045215","CDM","361","RC","49418","HCPCS",,,"facility","inpatient",,,,"11999","11999",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSR TUN IP CATH PERC","30045215","CDM","361","RC","49418","HCPCS",,,"facility","outpatient",,,,"11999","11999",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASC EMBOLIZE/OCCLUDE BLEED","30045229","CDM","361","RC","37244","HCPCS",,,"facility","inpatient",,,,"42090","42090",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VASC EMBOLIZE/OCCLUDE BLEED","30045229","CDM","361","RC","37244","HCPCS",,,"facility","outpatient",,,,"42090","42090",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMAGE CATH FLUID COLXN VISC","30045230","CDM","361","RC","49405","HCPCS",,,"facility","inpatient",,,,"5233","5233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMAGE CATH FLUID COLXN VISC","30045230","CDM","361","RC","49405","HCPCS",,,"facility","outpatient",,,,"5233","5233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMAGE CATH FLUID PERI/RETRO","30045231","CDM","361","RC","49406","HCPCS",,,"facility","inpatient",,,,"5613","5613",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMAGE CATH FLUID PERI/RETRO","30045231","CDM","361","RC","49406","HCPCS",,,"facility","outpatient",,,,"5613","5613",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMAGE CATH FLUID TRNS/VGNL","30045232","CDM","361","RC","49407","HCPCS",,,"facility","inpatient",,,,"6385","6385",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMAGE CATH FLUID TRNS/VGNL","30045232","CDM","361","RC","49407","HCPCS",,,"facility","outpatient",,,,"6385","6385",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST 1ST LESION STRTCTC BI","30045233","CDM","361","RC","19081","HCPCS",,,"facility","outpatient",,,"50","9321","9321",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BX BREAST ADD LESION STRTCTC LT","30045234","CDM","361","RC","19082","HCPCS",,,"facility","outpatient",,,"LT","3976","3976",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BX BREAST 1ST LESION US IMAG BI","30045235","CDM","361","RC","19083","HCPCS",,,"facility","outpatient",,,"50","8200","8200",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BX BREAST 1ST LESION MR IMAG LT","30045237","CDM","361","RC","19085","HCPCS",,,"facility","outpatient",,,"LT","6797","6797",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BX BREAST ADD LESION MR IMAG LT","30045238","CDM","361","RC","19086","HCPCS",,,"facility","outpatient",,,"LT","4436","4436",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INJ/ASPIRATION SMALL JNT/BURSA W/GUIDANCE &RPT","30045247","CDM","361","RC","20604","HCPCS",,,"facility","inpatient",,,,"2434","2434",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ/ASPIRATION SMALL JNT/BURSA W/GUIDANCE &RPT","30045247","CDM","361","RC","20604","HCPCS",,,"facility","outpatient",,,,"2110","2110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ/ASPIRATION INTER JNT/BURSA W/GUIDANCE &RPT","30045248","CDM","361","RC","20606","HCPCS",,,"facility","inpatient",,,,"2240","2240",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ/ASPIRATION INTER JNT/BURSA W/GUIDANCE &RPT","30045248","CDM","361","RC","20606","HCPCS",,,"facility","outpatient",,,,"1991","1991",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ/ASPIRATION MAJOR JNT/BURSA W/GUIDANCE &RPT","30045249","CDM","361","RC","20611","HCPCS",,,"facility","inpatient",,,,"1832","1832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ/ASPIRATION MAJOR JNT/BURSA W/GUIDANCE &RPT","30045249","CDM","361","RC","20611","HCPCS",,,"facility","outpatient",,,,"1832","1832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBROPLASTY INJ CERVIOTHORACIC UNI OR BI","30045250","CDM","361","RC","22510","HCPCS",,,"facility","inpatient",,,,"19982","19982",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBROPLASTY INJ CERVIOTHORACIC UNI OR BI","30045250","CDM","361","RC","22510","HCPCS",,,"facility","outpatient",,,,"19982","19982",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBROPLASTY INJ LUMBOSACRAL UNI OR BI","30045251","CDM","361","RC","22511","HCPCS",,,"facility","inpatient",,,,"16036","16036",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBROPLASTY INJ LUMBOSACRAL UNI OR BI","30045251","CDM","361","RC","22511","HCPCS",,,"facility","outpatient",,,,"16036","16036",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBROPLASTY INJ CERVO/LUMB EA ADDL","30045252","CDM","361","RC","22512","HCPCS",,,"facility","inpatient",,,,"10693","10693",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBROPLASTY INJ CERVO/LUMB EA ADDL","30045252","CDM","361","RC","22512","HCPCS",,,"facility","outpatient",,,,"10693","10693",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBRAL AUGMENTATION THORACIC UNI OR BI","30045253","CDM","361","RC","22513","HCPCS",,,"facility","inpatient",,,,"29093","29093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBRAL AUGMENTATION THORACIC UNI OR BI","30045253","CDM","361","RC","22513","HCPCS",,,"facility","outpatient",,,,"29093","29093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBRAL AUGMENTATION LUMBAR UNI OR BI","30045254","CDM","361","RC","22514","HCPCS",,,"facility","inpatient",,,,"24824","24824",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBRAL AUGMENTATION LUMBAR UNI OR BI","30045254","CDM","361","RC","22514","HCPCS",,,"facility","outpatient",,,,"24824","24824",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBRAL AUGMENTATION THOR/LUMBAR EA ADDL","30045255","CDM","361","RC","22515","HCPCS",,,"facility","inpatient",,,,"15694","15694",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC VERTEBRAL AUGMENTATION THOR/LUMBAR EA ADDL","30045255","CDM","361","RC","22515","HCPCS",,,"facility","outpatient",,,,"15694","15694",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRC MYELOGRAPHY LUMBAR IJ","30045256","CDM","361","RC","62304","HCPCS",,,"facility","inpatient",,,,"4465","4465",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRC MYELOGRAPHY LUMBAR IJ","30045256","CDM","361","RC","62304","HCPCS",,,"facility","outpatient",,,,"4465","4465",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRC MYELOGRAPHY LUMBAR IJ 2 OR MORE REGIONS","30045257","CDM","361","RC","62305","HCPCS",,,"facility","inpatient",,,,"4232","4232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRC MYELOGRAPHY LUMBAR IJ 2 OR MORE REGIONS","30045257","CDM","361","RC","62305","HCPCS",,,"facility","outpatient",,,,"4232","4232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CATH CAROTID/INOM ART CA BI","30045263","CDM","361","RC","36222","HCPCS",,,"facility","inpatient",,,"50","29412","29412",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CATH CAROTID/INOM ART CA BI","30045263","CDM","361","RC","36222","HCPCS",,,"facility","outpatient",,,"50","29412","29412",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CATH CAROTID/INOM ART XCA BI","30045264","CDM","361","RC","36223","HCPCS",,,"facility","inpatient",,,"50","40420","40420",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CATH CAROTID/INOM ART XCA BI","30045264","CDM","361","RC","36223","HCPCS",,,"facility","outpatient",,,"50","40420","40420",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLACE CATH CAROTD ART BI","30045265","CDM","361","RC","36224","HCPCS",,,"facility","inpatient",,,"50","37876","37876",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLACE CATH CAROTD ART BI","30045265","CDM","361","RC","36224","HCPCS",,,"facility","outpatient",,,"50","37876","37876",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLACE CATH SUBCLAVIAN ART BI","30045266","CDM","361","RC","36225","HCPCS",,,"facility","inpatient",,,"50","25874","25874",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLACE CATH SUBCLAVIAN ART BI","30045266","CDM","361","RC","36225","HCPCS",,,"facility","outpatient",,,"50","25874","25874",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLACE CATH VERTEBRAL ART BI","30045267","CDM","361","RC","36226","HCPCS",,,"facility","inpatient",,,"50","39856","39856",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLACE CATH VERTEBRAL ART BI","30045267","CDM","361","RC","36226","HCPCS",,,"facility","outpatient",,,"50","39856","39856",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CYSTO W FB/STNT RMV SMPL","30045270","CDM","361","RC","52310","HCPCS",,,"facility","inpatient",,,,"12928","12928",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTO W FB/STNT RMV SMPL","30045270","CDM","361","RC","52310","HCPCS",,,"facility","outpatient",,,,"12928","12928",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRC MYELOGRAPHY LUM IJ CERVICAL","30045272","CDM","361","RC","62302","HCPCS",,,"facility","inpatient",,,,"3821","3821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRC MYELOGRAPHY LUM IJ CERVICAL","30045272","CDM","361","RC","62302","HCPCS",,,"facility","outpatient",,,,"3821","3821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRC MYELOGRPHY LUM IJ THORACIC","30045273","CDM","361","RC","62303","HCPCS",,,"facility","inpatient",,,,"4456","4456",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRC MYELOGRPHY LUM IJ THORACIC","30045273","CDM","361","RC","62303","HCPCS",,,"facility","outpatient",,,,"4456","4456",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRVASC US NONCORONARY 1ST VSL","30045274","CDM","361","RC","37252","HCPCS",,,"facility","inpatient",,,,"11675","11675",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRVASC US NONCORONARY 1ST VSL","30045274","CDM","361","RC","37252","HCPCS",,,"facility","outpatient",,,,"11675","11675",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRVASC US NONCORONARY EACH ADDL VSL","30045275","CDM","361","RC","37253","HCPCS",,,"facility","inpatient",,,,"8124","8124",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRVASC US NONCORONARY EACH ADDL VSL","30045275","CDM","361","RC","37253","HCPCS",,,"facility","outpatient",,,,"8124","8124",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTN FOR CHOLANGIOGRAM EXISTNG ACCESS W/IMAGE","30045276","CDM","361","RC","47531","HCPCS",,,"facility","inpatient",,,,"5939","5939",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTN FOR CHOLANGIOGRAM EXISTNG ACCESS W/IMAGE","30045276","CDM","361","RC","47531","HCPCS",,,"facility","outpatient",,,,"5939","5939",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION FOR CHOLANGIOGRAM NEW ACCESS W/IMAGE","30045277","CDM","361","RC","47532","HCPCS",,,"facility","inpatient",,,,"4206","4206",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION FOR CHOLANGIOGRAM NEW ACCESS W/IMAGE","30045277","CDM","361","RC","47532","HCPCS",,,"facility","outpatient",,,,"4206","4206",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT BILIARY DRAINAGE CATH EXTERNAL W/IMAGE","30045278","CDM","361","RC","47533","HCPCS",,,"facility","inpatient",,,,"11400","11400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT BILIARY DRAINAGE CATH EXTERNAL W/IMAGE","30045278","CDM","361","RC","47533","HCPCS",,,"facility","outpatient",,,,"11400","11400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT BILIARY DRAINAGE CATH INTRNL EXTRNL W/IMAGE","30045279","CDM","361","RC","47534","HCPCS",,,"facility","inpatient",,,,"12874","12874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT BILIARY DRAINAGE CATH INTRNL EXTRNL W/IMAGE","30045279","CDM","361","RC","47534","HCPCS",,,"facility","outpatient",,,,"12874","12874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PROC ANTE NEPH/URETOR W/GUIDE NEW ACCESS","30045280","CDM","361","RC","50430","HCPCS",,,"facility","inpatient",,,,"3207","3207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PROC ANTE NEPH/URETOR W/GUIDE NEW ACCESS","30045280","CDM","361","RC","50430","HCPCS",,,"facility","outpatient",,,,"3207","3207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PROC ANTE NEPH/URETOR W/GUIDE INITAL ACCESS","30045281","CDM","361","RC","50431","HCPCS",,,"facility","inpatient",,,,"3986","3986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PROC ANTE NEPH/URETOR W/GUIDE INITAL ACCESS","30045281","CDM","361","RC","50431","HCPCS",,,"facility","outpatient",,,,"3986","3986",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACEMENT NEPHROSTOMY CATHETER W/GUIDE, S&I BI","30045282","CDM","361","RC","50432","HCPCS",,,"facility","inpatient",,,"50","13318","13318",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLACEMENT NEPHROSTOMY CATHETER W/GUIDE, S&I BI","30045282","CDM","361","RC","50432","HCPCS",,,"facility","outpatient",,,"50","13318","13318",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CONVERSION EXT BIL DRG CATH TO INT/EXT W/IMAGE","30045286","CDM","361","RC","47535","HCPCS",,,"facility","inpatient",,,,"11356","11356",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONVERSION EXT BIL DRG CATH TO INT/EXT W/IMAGE","30045286","CDM","361","RC","47535","HCPCS",,,"facility","outpatient",,,,"11356","11356",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXNG BILIARY DRG CATH INC CHOLANGRPHY W/IMGE","30045287","CDM","361","RC","47536","HCPCS",,,"facility","inpatient",,,,"10919","10919",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXNG BILIARY DRG CATH INC CHOLANGRPHY W/IMGE","30045287","CDM","361","RC","47536","HCPCS",,,"facility","outpatient",,,,"10919","10919",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC PLMT BILE DUCT EXISTNG ACCESS","30045288","CDM","361","RC","47538","HCPCS",,,"facility","inpatient",,,,"16894","16894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC PLMT BILE DUCT EXISTNG ACCESS","30045288","CDM","361","RC","47538","HCPCS",,,"facility","outpatient",,,,"16894","16894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT ACCESS BIL TREE SM BWL NEW ACCESS W/IMAGE","30045289","CDM","361","RC","47541","HCPCS",,,"facility","inpatient",,,,"7214","7214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT ACCESS BIL TREE SM BWL NEW ACCESS W/IMAGE","30045289","CDM","361","RC","47541","HCPCS",,,"facility","outpatient",,,,"7214","7214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DILATE BILIARY DUCT/AMPULLA EA DUCT W/IMAGE","30045290","CDM","361","RC","47542","HCPCS",,,"facility","inpatient",,,,"3687","3687",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DILATE BILIARY DUCT/AMPULLA EA DUCT W/IMAGE","30045290","CDM","361","RC","47542","HCPCS",,,"facility","outpatient",,,,"3687","3687",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDLMNL BX BILIARY TREE ANY MTHD SNGL/MLT W/IMG","30045291","CDM","361","RC","47543","HCPCS",,,"facility","inpatient",,,,"2293","2293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDLMNL BX BILIARY TREE ANY MTHD SNGL/MLT W/IMG","30045291","CDM","361","RC","47543","HCPCS",,,"facility","outpatient",,,,"2293","2293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMVL DCT GLBLDR CALC INCL DSTRCN ANY MTHD W/IMG","30045292","CDM","361","RC","47544","HCPCS",,,"facility","inpatient",,,,"5072","5072",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMVL DCT GLBLDR CALC INCL DSTRCN ANY MTHD W/IMG","30045292","CDM","361","RC","47544","HCPCS",,,"facility","outpatient",,,,"5072","5072",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC PLMT BILE DUCT NEW ACCESS WO PL CATH","30045293","CDM","361","RC","47539","HCPCS",,,"facility","inpatient",,,,"12518","12518",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC PLMT BILE DUCT NEW ACCESS WO PL CATH","30045293","CDM","361","RC","47539","HCPCS",,,"facility","outpatient",,,,"12518","12518",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SCLEROTX FLUID COLLCTN INCL CNTRST INJ W/IMAGE","30045294","CDM","361","RC","49185","HCPCS",,,"facility","inpatient",,,,"5564","5564",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SCLEROTX FLUID COLLCTN INCL CNTRST INJ W/IMAGE","30045294","CDM","361","RC","49185","HCPCS",,,"facility","outpatient",,,,"5564","5564",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRQ ART M THRMBCT &/NFS ANY MTHD W/IMAGE GDNCE","30045295","CDM","361","RC","61645","HCPCS",,,"facility","inpatient",,,,"48239","48239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRQ ART M THRMBCT &/NFS ANY MTHD W/IMAGE GDNCE","30045295","CDM","361","RC","61645","HCPCS",,,"facility","outpatient",,,,"48239","48239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASC PRLNG ADMN RX AGNT INTL W/IMAGE","30045296","CDM","361","RC","61650","HCPCS",,,"facility","inpatient",,,,"48972","48972",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASC PRLNG ADMN RX AGNT INTL W/IMAGE","30045296","CDM","361","RC","61650","HCPCS",,,"facility","outpatient",,,,"48972","48972",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASC PRLNG ADMN RX AGNT EA ADDL W/IMAGE","30045297","CDM","361","RC","61651","HCPCS",,,"facility","inpatient",,,,"46218","46218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVASC PRLNG ADMN RX AGNT EA ADDL W/IMAGE","30045297","CDM","361","RC","61651","HCPCS",,,"facility","outpatient",,,,"46218","46218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOLUMINAL BX URTR RENAL PELVIS W/GUIDE S&I","30045298","CDM","361","RC","50606","HCPCS",,,"facility","inpatient",,,,"5575","5575",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOLUMINAL BX URTR RENAL PELVIS W/GUIDE S&I","30045298","CDM","361","RC","50606","HCPCS",,,"facility","outpatient",,,,"5575","5575",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT URETERAL STENT PRQ W/O SEPARATE CATH","30045300","CDM","361","RC","50694","HCPCS",,,"facility","inpatient",,,,"12767","12767",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT URETERAL STENT PRQ W/O SEPARATE CATH","30045300","CDM","361","RC","50694","HCPCS",,,"facility","outpatient",,,,"12767","12767",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT URETERAL STENT PRQ W/SEPARATE CATH","30045301","CDM","361","RC","50695","HCPCS",,,"facility","inpatient",,,,"14056","14056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLMT URETERAL STENT PRQ W/SEPARATE CATH","30045301","CDM","361","RC","50695","HCPCS",,,"facility","outpatient",,,,"14056","14056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URETERAL EMBOLIZATION/OCCL","30045302","CDM","361","RC","50705","HCPCS",,,"facility","inpatient",,,,"6376","6376",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URETERAL EMBOLIZATION/OCCL","30045302","CDM","361","RC","50705","HCPCS",,,"facility","outpatient",,,,"6376","6376",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BALLOON DILATE URTRL STRIX","30045303","CDM","361","RC","50706","HCPCS",,,"facility","inpatient",,,,"8019","8019",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BALLOON DILATE URTRL STRIX","30045303","CDM","361","RC","50706","HCPCS",,,"facility","outpatient",,,,"8019","8019",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RML BIL DRNG CATH INCL DX CHOLANGIOGRPHY W/IMG","30045304","CDM","361","RC","47537","HCPCS",,,"facility","inpatient",,,,"3874","3874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RML BIL DRNG CATH INCL DX CHOLANGIOGRPHY W/IMG","30045304","CDM","361","RC","47537","HCPCS",,,"facility","outpatient",,,,"3874","3874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ PLMT BILE DUCT NEW ACCSS W PL CATH","30045305","CDM","361","RC","47540","HCPCS",,,"facility","inpatient",,,,"2390","2390",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ PLMT BILE DUCT NEW ACCSS W PL CATH","30045305","CDM","361","RC","47540","HCPCS",,,"facility","outpatient",,,,"2390","2390",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACEMENT NEPHROSTOMY CATHETER W/GUIDE, S&I LT","30045307","CDM","361","RC","50432","HCPCS",,,"facility","inpatient",,,"LT","8879","8879",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PLACEMENT NEPHROSTOMY CATHETER W/GUIDE, S&I LT","30045307","CDM","361","RC","50432","HCPCS",,,"facility","outpatient",,,"LT","8879","8879",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PLACEMENT NEPHROSTOMY CATHETER W/GUIDE, S&I RT","30045308","CDM","361","RC","50432","HCPCS",,,"facility","inpatient",,,"RT","8879","8879",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PLACEMENT NEPHROSTOMY CATHETER W/GUIDE, S&I RT","30045308","CDM","361","RC","50432","HCPCS",,,"facility","outpatient",,,"RT","8879","8879",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG ILIAC REVASC W/STENT BI","30045309","CDM","361","RC","37221","HCPCS",,,"facility","inpatient",,,"50","56643","56643",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG ILIAC REVASC W/STENT BI","30045309","CDM","361","RC","37221","HCPCS",,,"facility","outpatient",,,"50","56643","56643",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG ILIAC REVASC W/STENT LT","30045310","CDM","361","RC","37221","HCPCS",,,"facility","inpatient",,,"LT","37762","37762",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG ILIAC REVASC W/STENT LT","30045310","CDM","361","RC","37221","HCPCS",,,"facility","outpatient",,,"LT","37762","37762",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG ILIAC REVASC W/STENT RT","30045311","CDM","361","RC","37221","HCPCS",,,"facility","inpatient",,,"RT","37762","37762",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG ILIAC REVASC W/STENT RT","30045311","CDM","361","RC","37221","HCPCS",,,"facility","outpatient",,,"RT","37762","37762",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG ILIAC REVASC BI","30045312","CDM","361","RC","37220","HCPCS",,,"facility","inpatient",,,"50","38888","38888",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG ILIAC REVASC BI","30045312","CDM","361","RC","37220","HCPCS",,,"facility","outpatient",,,"50","38888","38888",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG ILIAC REVASC LT","30045313","CDM","361","RC","37220","HCPCS",,,"facility","inpatient",,,"LT","25925","25925",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG ILIAC REVASC LT","30045313","CDM","361","RC","37220","HCPCS",,,"facility","outpatient",,,"LT","25925","25925",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG ILIAC REVASC RT","30045314","CDM","361","RC","37220","HCPCS",,,"facility","inpatient",,,"RT","25925","25925",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG ILIAC REVASC RT","30045314","CDM","361","RC","37220","HCPCS",,,"facility","outpatient",,,"RT","25925","25925",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PLMT NEPHROURETERAL CATH W/GUIDE S&I NEW ACCESS BI","30045318","CDM","361","RC","50433","HCPCS",,,"facility","inpatient",,,"50","15432","15432",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLMT NEPHROURETERAL CATH W/GUIDE S&I NEW ACCESS BI","30045318","CDM","361","RC","50433","HCPCS",,,"facility","outpatient",,,"50","15432","15432",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLMT NEPHROURETERAL CATH W/GUIDE S&I NEW ACCESS LT","30045319","CDM","361","RC","50433","HCPCS",,,"facility","inpatient",,,"LT","10288","10288",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PLMT NEPHROURETERAL CATH W/GUIDE S&I NEW ACCESS LT","30045319","CDM","361","RC","50433","HCPCS",,,"facility","outpatient",,,"LT","10288","10288",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PLMT NEPHROURETERAL CATH W/GUIDE S&I NEW ACCESS RT","30045320","CDM","361","RC","50433","HCPCS",,,"facility","inpatient",,,"RT","10288","10288",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PLMT NEPHROURETERAL CATH W/GUIDE S&I NEW ACCESS RT","30045320","CDM","361","RC","50433","HCPCS",,,"facility","outpatient",,,"RT","10288","10288",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CONVERT NEPHROSTOMY CATHETER W/GUIDE S&I BI","30045321","CDM","361","RC","50434","HCPCS",,,"facility","inpatient",,,"50","12388","12388",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CONVERT NEPHROSTOMY CATHETER W/GUIDE S&I BI","30045321","CDM","361","RC","50434","HCPCS",,,"facility","outpatient",,,"50","12388","12388",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CONVERT NEPHROSTOMY CATHETER W/GUIDE S&I RT","30045323","CDM","361","RC","50434","HCPCS",,,"facility","inpatient",,,"RT","8259","8259",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CONVERT NEPHROSTOMY CATHETER W/GUIDE S&I RT","30045323","CDM","361","RC","50434","HCPCS",,,"facility","outpatient",,,"RT","8259","8259",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG EXCHANGE NEPHROSTOMY CATH W/GUIDE S&I BI","30045324","CDM","361","RC","50435","HCPCS",,,"facility","inpatient",,,"50","11208","11208",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG EXCHANGE NEPHROSTOMY CATH W/GUIDE S&I BI","30045324","CDM","361","RC","50435","HCPCS",,,"facility","outpatient",,,"50","11208","11208",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG EXCHANGE NEPHROSTOMY CATH W/GUIDE S&I LT","30045325","CDM","361","RC","50435","HCPCS",,,"facility","inpatient",,,"LT","7472","7472",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG EXCHANGE NEPHROSTOMY CATH W/GUIDE S&I LT","30045325","CDM","361","RC","50435","HCPCS",,,"facility","outpatient",,,"LT","7472","7472",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG EXCHANGE NEPHROSTOMY CATH W/GUIDE S&I RT","30045326","CDM","361","RC","50435","HCPCS",,,"facility","inpatient",,,"RT","7472","7472",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG EXCHANGE NEPHROSTOMY CATH W/GUIDE S&I RT","30045326","CDM","361","RC","50435","HCPCS",,,"facility","outpatient",,,"RT","7472","7472",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG THORACENTESIS W/IMAGING LT","30045330","CDM","361","RC","32555","HCPCS",,,"facility","inpatient",,,"LT","3790","3790",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG THORACENTESIS W/IMAGING LT","30045330","CDM","361","RC","32555","HCPCS",,,"facility","outpatient",,,"LT","3790","3790",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG THORACENTESIS W/IMAGING RT","30045331","CDM","361","RC","32555","HCPCS",,,"facility","inpatient",,,"RT","3790","3790",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG THORACENTESIS W/IMAGING RT","30045331","CDM","361","RC","32555","HCPCS",,,"facility","outpatient",,,"RT","3790","3790",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG THORACENTESIS W/IMAGING BI","30045332","CDM","361","RC","32555","HCPCS",,,"facility","inpatient",,,"50","5685","5685",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG THORACENTESIS W/IMAGING BI","30045332","CDM","361","RC","32555","HCPCS",,,"facility","outpatient",,,"50","5685","5685",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLMT URETERAL STENT PRQ PREEXIST TRACT BI","30045335","CDM","361","RC","50693","HCPCS",,,"facility","inpatient",,,"50","16569","16569",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLMT URETERAL STENT PRQ PREEXIST TRACT BI","30045335","CDM","361","RC","50693","HCPCS",,,"facility","outpatient",,,"50","16569","16569",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PLMT URETERAL STENT PRQ PREEXIST TRACT LT","30045336","CDM","361","RC","50693","HCPCS",,,"facility","inpatient",,,"LT","11046","11046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PLMT URETERAL STENT PRQ PREEXIST TRACT LT","30045336","CDM","361","RC","50693","HCPCS",,,"facility","outpatient",,,"LT","11046","11046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PLMT URETERAL STENT PRQ PREEXIST TRACT RT","30045337","CDM","361","RC","50693","HCPCS",,,"facility","inpatient",,,"RT","11046","11046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PLMT URETERAL STENT PRQ PREEXIST TRACT RT","30045337","CDM","361","RC","50693","HCPCS",,,"facility","outpatient",,,"RT","11046","11046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG EMBEDDED IP CATH EXIT SITE","30045344","CDM","361","RC","49436","HCPCS",,,"facility","inpatient",,,,"5264","5264",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMBEDDED IP CATH EXIT SITE","30045344","CDM","361","RC","49436","HCPCS",,,"facility","outpatient",,,,"5264","5264",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX BREAST ADD LESION STRTCTC RT","30045346","CDM","361","RC","19082","HCPCS",,,"facility","outpatient",,,"RT","3976","3976",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BX BREAST 1ST LESION MR IMAG RT","30045347","CDM","361","RC","19085","HCPCS",,,"facility","outpatient",,,"RT","6797","6797",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BX BREAST ADD LESION MR IMAG RT","30045348","CDM","361","RC","19086","HCPCS",,,"facility","outpatient",,,"RT","4436","4436",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RMV OBSTRUC FRM COLONIC TUBE, W/FLUOR & W/CONT","30045670","CDM","361","RC","49460","HCPCS",,,"facility","inpatient",,,,"2397","2397",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMV OBSTRUC FRM COLONIC TUBE, W/FLUOR & W/CONT","30045670","CDM","361","RC","49460","HCPCS",,,"facility","outpatient",,,,"2397","2397",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D HEMATOMA, ABSCESS, BURSA THIGH/KNEE REGION","30045673","CDM","361","RC","27301","HCPCS",,,"facility","inpatient",,,,"14739","14739",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D HEMATOMA, ABSCESS, BURSA THIGH/KNEE REGION","30045673","CDM","361","RC","27301","HCPCS",,,"facility","outpatient",,,,"14739","14739",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPR CV CATH W PORT","30045675","CDM","361","RC","36576","HCPCS",,,"facility","inpatient",,,,"4645","4645",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPR CV CATH W PORT","30045675","CDM","361","RC","36576","HCPCS",,,"facility","outpatient",,,,"4645","4645",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION AIR CON PERITNL","30045677","CDM","361","RC","49400","HCPCS",,,"facility","inpatient",,,,"947","947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION AIR CON PERITNL","30045677","CDM","361","RC","49400","HCPCS",,,"facility","outpatient",,,,"947","947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE DUODEN OR JEJUN TUBE PERC W/FLUORO & W/CON","30045678","CDM","361","RC","49441","HCPCS",,,"facility","inpatient",,,,"4280","4280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE DUODEN OR JEJUN TUBE PERC W/FLUORO & W/CON","30045678","CDM","361","RC","49441","HCPCS",,,"facility","outpatient",,,,"4280","4280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE DUODENOSTOMY OR JEJUN TUBE PERC W/FLUORO","30045680","CDM","361","RC","49451","HCPCS",,,"facility","inpatient",,,,"4025","4025",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE DUODENOSTOMY OR JEJUN TUBE PERC W/FLUORO","30045680","CDM","361","RC","49451","HCPCS",,,"facility","outpatient",,,,"4025","4025",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE URET STNT INT","30045682","CDM","361","RC","50384","HCPCS",,,"facility","inpatient",,,,"6908","6908",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE URET STNT INT","30045682","CDM","361","RC","50384","HCPCS",,,"facility","outpatient",,,,"6908","6908",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTO TUBE CHNG SMPL","30045683","CDM","361","RC","51705","HCPCS",,,"facility","inpatient",,,,"1342","1342",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTO TUBE CHNG SMPL","30045683","CDM","361","RC","51705","HCPCS",,,"facility","outpatient",,,,"1342","1342",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PV FACET C/T 2 LVL","30045685","CDM","361","RC","64491","HCPCS",,,"facility","inpatient",,,,"1931","1931",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PV FACET C/T 2 LVL","30045685","CDM","361","RC","64491","HCPCS",,,"facility","outpatient",,,,"1931","1931",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PV FACET W IMAGE GUIDANCE L/S 2ND LVL","30045686","CDM","361","RC","64494","HCPCS",,,"facility","inpatient",,,,"2156","2156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION PV FACET W IMAGE GUIDANCE L/S 2ND LVL","30045686","CDM","361","RC","64494","HCPCS",,,"facility","outpatient",,,,"2156","2156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO EXT UNI LT","30045691","CDM","323","RC","75710","HCPCS",,,"facility","inpatient",,,"LT","10621","10621",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG IR ANGIO EXT UNI LT","30045691","CDM","323","RC","75710","HCPCS",,,"facility","outpatient",,,"LT","10621","10621",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG IR ANGIO EXT UNI RT","30045692","CDM","323","RC","75710","HCPCS",,,"facility","inpatient",,,"RT","10621","10621",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG IR ANGIO EXT UNI RT","30045692","CDM","323","RC","75710","HCPCS",,,"facility","outpatient",,,"RT","10621","10621",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR VENOGRAM EXT UNI LT","30045695","CDM","320","RC","75820","HCPCS",,,"facility","inpatient",,,"LT","3907","3907",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR VENOGRAM EXT UNI LT","30045695","CDM","320","RC","75820","HCPCS",,,"facility","outpatient",,,"LT","3907","3907",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR VENOGRAM EXT UNI RT","30045696","CDM","320","RC","75820","HCPCS",,,"facility","inpatient",,,"RT","3907","3907",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR VENOGRAM EXT UNI RT","30045696","CDM","320","RC","75820","HCPCS",,,"facility","outpatient",,,"RT","3907","3907",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR VENOGRAM RENL UNI LT","30045697","CDM","320","RC","75831","HCPCS",,,"facility","inpatient",,,"LT","5147","5147",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR VENOGRAM RENL UNI LT","30045697","CDM","320","RC","75831","HCPCS",,,"facility","outpatient",,,"LT","5147","5147",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR VENOGRAM RENL UNI RT","30045698","CDM","320","RC","75831","HCPCS",,,"facility","inpatient",,,"RT","5147","5147",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR VENOGRAM RENL UNI RT","30045698","CDM","320","RC","75831","HCPCS",,,"facility","outpatient",,,"RT","5147","5147",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR SPINE SINGLE VIEW","30045711","CDM","320","RC","72020","HCPCS",,,"facility","inpatient",,,,"729","729",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR SPINE SINGLE VIEW","30045711","CDM","320","RC","72020","HCPCS",,,"facility","outpatient",,,,"729","729",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS CATH REN ART 1ST UNILAT","30045716","CDM","361","RC","36251","HCPCS",,,"facility","inpatient",,,,"13523","13523",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS CATH REN ART 1ST UNILAT","30045716","CDM","361","RC","36251","HCPCS",,,"facility","outpatient",,,,"13523","13523",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS CATH REN ART 1ST BI","30045718","CDM","361","RC","36252","HCPCS",,,"facility","inpatient",,,,"14947","14947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS CATH REN ART 1ST BI","30045718","CDM","361","RC","36252","HCPCS",,,"facility","outpatient",,,,"14947","14947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS CATH REN ART 2ND+ UNILAT","30045720","CDM","361","RC","36253","HCPCS",,,"facility","inpatient",,,,"13800","13800",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS CATH REN ART 2ND+ UNILAT","30045720","CDM","361","RC","36253","HCPCS",,,"facility","outpatient",,,,"13800","13800",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS CATH REN ART 2ND+ BILAT","30045722","CDM","361","RC","36254","HCPCS",,,"facility","inpatient",,,,"7520","7520",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS CATH REN ART 2ND+ BILAT","30045722","CDM","361","RC","36254","HCPCS",,,"facility","outpatient",,,,"7520","7520",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT ENDOVASCULAR VENA CAVA FILTER","30045723","CDM","361","RC","37191","HCPCS",,,"facility","inpatient",,,,"17462","17462",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT ENDOVASCULAR VENA CAVA FILTER","30045723","CDM","361","RC","37191","HCPCS",,,"facility","outpatient",,,,"17462","17462",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REDO ENDOVAS VENA CAVA FILTR","30045724","CDM","361","RC","37192","HCPCS",,,"facility","inpatient",,,,"19996","19996",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REDO ENDOVAS VENA CAVA FILTR","30045724","CDM","361","RC","37192","HCPCS",,,"facility","outpatient",,,,"19996","19996",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REM ENDOVAS VENA CAVA FILTER","30045725","CDM","361","RC","37193","HCPCS",,,"facility","inpatient",,,,"17483","17483",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REM ENDOVAS VENA CAVA FILTER","30045725","CDM","361","RC","37193","HCPCS",,,"facility","outpatient",,,,"17483","17483",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABD PARACENTESIS W/IMAGING","30045727","CDM","361","RC","49083","HCPCS",,,"facility","inpatient",,,,"3952","3952",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABD PARACENTESIS W/IMAGING","30045727","CDM","361","RC","49083","HCPCS",,,"facility","outpatient",,,,"3952","3952",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY CERV/THOR FACET JNT","30045729","CDM","361","RC","64633","HCPCS",,,"facility","inpatient",,,,"7008","7008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY CERV/THOR FACET JNT","30045729","CDM","361","RC","64633","HCPCS",,,"facility","outpatient",,,,"7008","7008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY C/TH FACET JNT ADDL","30045730","CDM","361","RC","64634","HCPCS",,,"facility","inpatient",,,,"3476","3476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY C/TH FACET JNT ADDL","30045730","CDM","361","RC","64634","HCPCS",,,"facility","outpatient",,,,"3476","3476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY LUMB/SAC FACET JNT","30045731","CDM","361","RC","64635","HCPCS",,,"facility","inpatient",,,,"5967","5967",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY LUMB/SAC FACET JNT","30045731","CDM","361","RC","64635","HCPCS",,,"facility","outpatient",,,,"5967","5967",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY L/S FACET JNT ADDL","30045732","CDM","361","RC","64636","HCPCS",,,"facility","inpatient",,,,"3365","3365",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY L/S FACET JNT ADDL","30045732","CDM","361","RC","64636","HCPCS",,,"facility","outpatient",,,,"3365","3365",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ANGIO ABD&PELV W/O&W/DYE","30045734","CDM","352","RC","74174","HCPCS",,,"facility","inpatient",,,,"9849","9849",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ANGIO ABD&PELV W/O&W/DYE","30045734","CDM","352","RC","74174","HCPCS",,,"facility","outpatient",,,,"9849","9849",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION VESSEL","30045744","CDM","361","RC","36299","HCPCS",,,"facility","inpatient",,,,"1828","1828",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION VESSEL","30045744","CDM","361","RC","36299","HCPCS",,,"facility","outpatient",,,,"1828","1828",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IR ANGIO ADRENAL UNI LT","30045753","CDM","323","RC","75731","HCPCS",,,"facility","inpatient",,,"LT","5619","5619",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG IR ANGIO ADRENAL UNI LT","30045753","CDM","323","RC","75731","HCPCS",,,"facility","outpatient",,,"LT","5619","5619",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG IR ANGIO ADRENAL UNI RT","30045754","CDM","323","RC","75731","HCPCS",,,"facility","inpatient",,,"RT","5619","5619",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG IR ANGIO ADRENAL UNI RT","30045754","CDM","323","RC","75731","HCPCS",,,"facility","outpatient",,,"RT","5619","5619",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG IR ANGIO PULM UNI SEL LT","30045755","CDM","323","RC","75741","HCPCS",,,"facility","inpatient",,,"LT","3793","3793",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG IR ANGIO PULM UNI SEL LT","30045755","CDM","323","RC","75741","HCPCS",,,"facility","outpatient",,,"LT","3793","3793",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG IR ANGIO PULM UNI SEL RT","30045756","CDM","323","RC","75741","HCPCS",,,"facility","inpatient",,,"RT","3793","3793",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG IR ANGIO PULM UNI SEL RT","30045756","CDM","323","RC","75741","HCPCS",,,"facility","outpatient",,,"RT","3793","3793",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR VENOGRAM ADRENL UNI LT","30045757","CDM","320","RC","75840","HCPCS",,,"facility","inpatient",,,"LT","4263","4263",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR VENOGRAM ADRENL UNI LT","30045757","CDM","320","RC","75840","HCPCS",,,"facility","outpatient",,,"LT","4263","4263",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR VENOGRAM ADRENL UNI RT","30045758","CDM","320","RC","75840","HCPCS",,,"facility","inpatient",,,"RT","4263","4263",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR VENOGRAM ADRENL UNI RT","30045758","CDM","320","RC","75840","HCPCS",,,"facility","outpatient",,,"RT","4263","4263",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG ENDOVENOUS RF 1ST VEIN","30045775","CDM","361","RC","36475","HCPCS",,,"facility","inpatient",,,,"12293","12293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENDOVENOUS RF 1ST VEIN","30045775","CDM","361","RC","36475","HCPCS",,,"facility","outpatient",,,,"12293","12293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR TMJ UNILATERAL LT","30045781","CDM","320","RC","70328","HCPCS",,,"facility","inpatient",,,"LT","423","423",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR TMJ UNILATERAL LT","30045781","CDM","320","RC","70328","HCPCS",,,"facility","outpatient",,,"LT","423","423",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG XR TMJ UNILATERAL RT","30045782","CDM","320","RC","70328","HCPCS",,,"facility","inpatient",,,"RT","423","423",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG XR TMJ UNILATERAL RT","30045782","CDM","320","RC","70328","HCPCS",,,"facility","outpatient",,,"RT","423","423",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG I&D ABSC/HEMA NK/THOR","30045783","CDM","361","RC","21501","HCPCS",,,"facility","inpatient",,,,"16688","16688",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I&D ABSC/HEMA NK/THOR","30045783","CDM","361","RC","21501","HCPCS",,,"facility","outpatient",,,,"16688","16688",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CANNULATION THOR DUCT","30045806","CDM","361","RC","38794","HCPCS",,,"facility","inpatient",,,,"4354","4354",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CANNULATION THOR DUCT","30045806","CDM","361","RC","38794","HCPCS",,,"facility","outpatient",,,,"4354","4354",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESTROY CERV/THOR FACET JNT BIL","30045812","CDM","361","RC","64633","HCPCS",,,"facility","inpatient",,,"50","10512","10512",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DESTROY CERV/THOR FACET JNT BIL","30045812","CDM","361","RC","64633","HCPCS",,,"facility","outpatient",,,"50","10512","10512",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ NRV AA/STRD GREATER OCCIPITAL BIL","30045814","CDM","361","RC","64405","HCPCS",,,"facility","inpatient",,,"50","2466","2466",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ NRV AA/STRD GREATER OCCIPITAL BIL","30045814","CDM","361","RC","64405","HCPCS",,,"facility","outpatient",,,"50","2466","2466",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJS ANES&STRD W/IMG TFRML EDRL CRV/THR 1 LV BIL","30045816","CDM","361","RC","64479","HCPCS",,,"facility","inpatient",,,"50","6646","6646",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJS ANES&STRD W/IMG TFRML EDRL CRV/THR 1 LV BIL","30045816","CDM","361","RC","64479","HCPCS",,,"facility","outpatient",,,"50","6646","6646",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJS ANES/STRD IMG TFRML EDRL LMBR/SAC 1 LVL BIL","30045818","CDM","361","RC","64483","HCPCS",,,"facility","inpatient",,,"50","7352","7352",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJS ANES/STRD IMG TFRML EDRL LMBR/SAC 1 LVL BIL","30045818","CDM","361","RC","64483","HCPCS",,,"facility","outpatient",,,"50","7352","7352",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ AA/STRD OTHER PERIPH/BRANCH BIL","30045822","CDM","361","RC","64450","HCPCS",,,"facility","inpatient",,,"50","3370","3370",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ AA/STRD OTHER PERIPH/BRANCH BIL","30045822","CDM","361","RC","64450","HCPCS",,,"facility","outpatient",,,"50","3370","3370",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ NRV AA/STRD SCIATIC IMG BIL","30045823","CDM","361","RC","64445","HCPCS",,,"facility","inpatient",,,"50","5244","5244",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INJ NRV AA/STRD SCIATIC IMG BIL","30045823","CDM","361","RC","64445","HCPCS",,,"facility","outpatient",,,"50","5244","5244",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DESTROY LUMB/SAC FACET JNT BIL","30045829","CDM","361","RC","64635","HCPCS",,,"facility","inpatient",,,"50","8950","8950",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DESTROY LUMB/SAC FACET JNT BIL","30045829","CDM","361","RC","64635","HCPCS",,,"facility","outpatient",,,"50","8950","8950",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INSERT CATH PLEURA W/O IMAGE","30045830","CDM","361","RC","32556","HCPCS",,,"facility","inpatient",,,,"3808","3808",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT CATH PLEURA W/O IMAGE","30045830","CDM","361","RC","32556","HCPCS",,,"facility","outpatient",,,,"3808","3808",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US GUIDE ART PSEUDOANEUR","30100002","CDM","402","RC","76936","HCPCS",,,"facility","inpatient",,,,"2297","2297",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US GUIDE ART PSEUDOANEUR","30100002","CDM","402","RC","76936","HCPCS",,,"facility","outpatient",,,,"2297","2297",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US INTRAOP","30100003","CDM","402","RC","76998","HCPCS",,,"facility","inpatient",,,,"1642","1642",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US INTRAOP","30100003","CDM","402","RC","76998","HCPCS",,,"facility","outpatient",,,,"1642","1642",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ENCEPHALOGRAM","30100004","CDM","402","RC","76506","HCPCS",,,"facility","inpatient",,,,"1788","1788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ENCEPHALOGRAM","30100004","CDM","402","RC","76506","HCPCS",,,"facility","outpatient",,,,"1788","1788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OPHTHALMIC B-SCAN BIL","30100005","CDM","402","RC","76512","HCPCS",,,"facility","inpatient",,,"50","972","972",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG US OPHTHALMIC B-SCAN BIL","30100005","CDM","402","RC","76512","HCPCS",,,"facility","outpatient",,,"50","972","972",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG US OPHTHALMIC B-SCAN LT","30100006","CDM","402","RC","76512","HCPCS",,,"facility","inpatient",,,"LT","648","648",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US OPHTHALMIC B-SCAN LT","30100006","CDM","402","RC","76512","HCPCS",,,"facility","outpatient",,,"LT","648","648",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US OPHTHALMIC B-SCAN RT","30100007","CDM","402","RC","76512","HCPCS",,,"facility","inpatient",,,"RT","648","648",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US OPHTHALMIC B-SCAN RT","30100007","CDM","402","RC","76512","HCPCS",,,"facility","outpatient",,,"RT","648","648",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US OPHTHALMIC ANTERIOR SEGMENT IMMERSION BI","30100008","CDM","402","RC","76513","HCPCS",,,"facility","inpatient",,,"50","6118","6118",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG US OPHTHALMIC ANTERIOR SEGMENT IMMERSION BI","30100008","CDM","402","RC","76513","HCPCS",,,"facility","outpatient",,,"50","6118","6118",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG US OPHTHALMIC ANTERIOR SEGMENT IMMERSION LT","30100009","CDM","402","RC","76513","HCPCS",,,"facility","inpatient",,,"LT","4079","4079",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US OPHTHALMIC ANTERIOR SEGMENT IMMERSION LT","30100009","CDM","402","RC","76513","HCPCS",,,"facility","outpatient",,,"LT","4079","4079",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US OPHTHALMIC ANTERIOR SEGMENT IMMERSION RT","30100010","CDM","402","RC","76513","HCPCS",,,"facility","inpatient",,,"RT","4079","4079",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US OPHTHALMIC ANTERIOR SEGMENT IMMERSION RT","30100010","CDM","402","RC","76513","HCPCS",,,"facility","outpatient",,,"RT","4079","4079",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US OPHTHALMIC BIOMETRY A SCAN","30100011","CDM","402","RC","76516","HCPCS",,,"facility","inpatient",,,,"402","402",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OPHTHALMIC BIOMETRY A SCAN","30100011","CDM","402","RC","76516","HCPCS",,,"facility","outpatient",,,,"402","402",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US HEAD AND NECK SOFT TISSUE","30100013","CDM","402","RC","76536","HCPCS",,,"facility","inpatient",,,,"1368","1368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US HEAD AND NECK SOFT TISSUE","30100013","CDM","402","RC","76536","HCPCS",,,"facility","outpatient",,,,"1368","1368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US CHEST","30100014","CDM","402","RC","76604","HCPCS",,,"facility","inpatient",,,,"1377","1377",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US CHEST","30100014","CDM","402","RC","76604","HCPCS",,,"facility","outpatient",,,,"1377","1377",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ABD COMPLETE","30100016","CDM","402","RC","76700","HCPCS",,,"facility","inpatient",,,,"1887","1887",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ABD COMPLETE","30100016","CDM","402","RC","76700","HCPCS",,,"facility","outpatient",,,,"1887","1887",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ABD LTD","30100017","CDM","402","RC","76705","HCPCS",,,"facility","inpatient",,,,"1656","1656",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ABD LTD","30100017","CDM","402","RC","76705","HCPCS",,,"facility","outpatient",,,,"1656","1656",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US RETROPERITONEUM COMPLETE","30100018","CDM","402","RC","76770","HCPCS",,,"facility","inpatient",,,,"1666","1666",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US RETROPERITONEUM COMPLETE","30100018","CDM","402","RC","76770","HCPCS",,,"facility","outpatient",,,,"1666","1666",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US RETROPERITONEUM LTD","30100019","CDM","402","RC","76775","HCPCS",,,"facility","inpatient",,,,"1330","1330",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US RETROPERITONEUM LTD","30100019","CDM","402","RC","76775","HCPCS",,,"facility","outpatient",,,,"1330","1330",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TRANSPLNT KDNY W/DPPLR","30100020","CDM","402","RC","76776","HCPCS",,,"facility","inpatient",,,,"1984","1984",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TRANSPLNT KDNY W/DPPLR","30100020","CDM","402","RC","76776","HCPCS",,,"facility","outpatient",,,,"1984","1984",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US SPINAL CANAL","30100021","CDM","402","RC","76800","HCPCS",,,"facility","inpatient",,,,"1641","1641",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US SPINAL CANAL","30100021","CDM","402","RC","76800","HCPCS",,,"facility","outpatient",,,,"1641","1641",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB < 14 WEEKS SINGLE FETUS","30100022","CDM","402","RC","76801","HCPCS",,,"facility","inpatient",,,,"1625","1625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB < 14 WEEKS SINGLE FETUS","30100022","CDM","402","RC","76801","HCPCS",,,"facility","outpatient",,,,"1625","1625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB < 14 WEEKS ADDL FETUS","30100023","CDM","402","RC","76802","HCPCS",,,"facility","inpatient",,,,"368","368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB < 14 WEEKS ADDL FETUS","30100023","CDM","402","RC","76802","HCPCS",,,"facility","outpatient",,,,"368","368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB > 14 WEEKS SINGLE FETUS","30100024","CDM","402","RC","76805","HCPCS",,,"facility","inpatient",,,,"1479","1479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB > 14 WEEKS SINGLE FETUS","30100024","CDM","402","RC","76805","HCPCS",,,"facility","outpatient",,,,"1479","1479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB > 14 WEEKS ADDL FETUS","30100025","CDM","402","RC","76810","HCPCS",,,"facility","inpatient",,,,"1089","1089",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB > 14 WEEKS ADDL FETUS","30100025","CDM","402","RC","76810","HCPCS",,,"facility","outpatient",,,,"1089","1089",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB DETAILED SINGLE FETUS","30100026","CDM","402","RC","76811","HCPCS",,,"facility","inpatient",,,,"1665","1665",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB DETAILED SINGLE FETUS","30100026","CDM","402","RC","76811","HCPCS",,,"facility","outpatient",,,,"1665","1665",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB DETAILED ADDL FETUS","30100027","CDM","402","RC","76812","HCPCS",,,"facility","inpatient",,,,"3959","3959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB DETAILED ADDL FETUS","30100027","CDM","402","RC","76812","HCPCS",,,"facility","outpatient",,,,"3959","3959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB NUCHAL MEAS FIRST GESTATION","30100028","CDM","402","RC","76813","HCPCS",,,"facility","inpatient",,,,"769","769",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB NUCHAL MEAS FIRST GESTATION","30100028","CDM","402","RC","76813","HCPCS",,,"facility","outpatient",,,,"769","769",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB NUCHAL MEAS ADD-ON","30100029","CDM","402","RC","76814","HCPCS",,,"facility","inpatient",,,,"930","930",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB NUCHAL MEAS ADD-ON","30100029","CDM","402","RC","76814","HCPCS",,,"facility","outpatient",,,,"930","930",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB LTD 1 OR MORE FETUS","30100030","CDM","402","RC","76815","HCPCS",,,"facility","inpatient",,,,"1194","1194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB LTD 1 OR MORE FETUS","30100030","CDM","402","RC","76815","HCPCS",,,"facility","outpatient",,,,"1194","1194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB FOLLOW-UP RE-EVAL PER FETUS","30100031","CDM","402","RC","76816","HCPCS",,,"facility","inpatient",,,,"894","894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB FOLLOW-UP RE-EVAL PER FETUS","30100031","CDM","402","RC","76816","HCPCS",,,"facility","outpatient",,,,"894","894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB TRANSVAGINAL","30100032","CDM","402","RC","76817","HCPCS",,,"facility","inpatient",,,,"1457","1457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB TRANSVAGINAL","30100032","CDM","402","RC","76817","HCPCS",,,"facility","outpatient",,,,"1457","1457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US BIO PROFILE W NONSTRESS","30100033","CDM","402","RC","76818","HCPCS",,,"facility","inpatient",,,,"1705","1705",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US BIO PROFILE W NONSTRESS","30100033","CDM","402","RC","76818","HCPCS",,,"facility","outpatient",,,,"1705","1705",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US BIO PROFILE WO NONSTRESS","30100034","CDM","402","RC","76819","HCPCS",,,"facility","inpatient",,,,"1579","1579",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US BIO PROFILE WO NONSTRESS","30100034","CDM","402","RC","76819","HCPCS",,,"facility","outpatient",,,,"1579","1579",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB UMBILLICAL ARTERY","30100035","CDM","402","RC","76820","HCPCS",,,"facility","inpatient",,,,"742","742",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB UMBILLICAL ARTERY","30100035","CDM","402","RC","76820","HCPCS",,,"facility","outpatient",,,,"742","742",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB MID CEREBRAL ARTERY","30100036","CDM","402","RC","76821","HCPCS",,,"facility","inpatient",,,,"1368","1368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OB MID CEREBRAL ARTERY","30100036","CDM","402","RC","76821","HCPCS",,,"facility","outpatient",,,,"1368","1368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US M-MODE FETAL","30100037","CDM","402","RC","76825","HCPCS",,,"facility","inpatient",,,,"3464","3464",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US M-MODE FETAL","30100037","CDM","402","RC","76825","HCPCS",,,"facility","outpatient",,,,"3464","3464",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US DOPPLER ECHO FETAL","30100038","CDM","402","RC","76827","HCPCS",,,"facility","inpatient",,,,"875","875",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US DOPPLER ECHO FETAL","30100038","CDM","402","RC","76827","HCPCS",,,"facility","outpatient",,,,"875","875",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TRANSVAGINAL NON-OB","30100039","CDM","402","RC","76830","HCPCS",,,"facility","inpatient",,,,"1310","1310",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TRANSVAGINAL NON-OB","30100039","CDM","402","RC","76830","HCPCS",,,"facility","outpatient",,,,"1310","1310",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US SONOHYSTEROGRAM SALINE INFUSION","30100040","CDM","402","RC","76831","HCPCS",,,"facility","inpatient",,,,"1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US SONOHYSTEROGRAM SALINE INFUSION","30100040","CDM","402","RC","76831","HCPCS",,,"facility","outpatient",,,,"1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US PELVIC COMPLETE NON-OB","30100041","CDM","402","RC","76856","HCPCS",,,"facility","inpatient",,,,"1596","1596",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US PELVIC COMPLETE NON-OB","30100041","CDM","402","RC","76856","HCPCS",,,"facility","outpatient",,,,"1596","1596",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US PELVIC LTD FOLLOW-UP NON-OB","30100042","CDM","402","RC","76857","HCPCS",,,"facility","inpatient",,,,"944","944",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US PELVIC LTD FOLLOW-UP NON-OB","30100042","CDM","402","RC","76857","HCPCS",,,"facility","outpatient",,,,"944","944",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TESTICULAR SCROTUM","30100043","CDM","402","RC","76870","HCPCS",,,"facility","inpatient",,,,"1538","1538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TESTICULAR SCROTUM","30100043","CDM","402","RC","76870","HCPCS",,,"facility","outpatient",,,,"1538","1538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TRANSRECTAL","30100044","CDM","402","RC","76872","HCPCS",,,"facility","inpatient",,,,"1088","1088",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TRANSRECTAL","30100044","CDM","402","RC","76872","HCPCS",,,"facility","outpatient",,,,"1088","1088",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ECHO PROSTATE VOL STDY","30100045","CDM","402","RC","76873","HCPCS",,,"facility","inpatient",,,,"1316","1316",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ECHO PROSTATE VOL STDY","30100045","CDM","402","RC","76873","HCPCS",,,"facility","outpatient",,,,"1316","1316",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US INFANT HIPS R-T IMG DYNAMIC WITH MANIPULATION","30100048","CDM","402","RC","76885","HCPCS",,,"facility","inpatient",,,,"2292","2292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US INFANT HIPS R-T IMG DYNAMIC WITH MANIPULATION","30100048","CDM","402","RC","76885","HCPCS",,,"facility","outpatient",,,,"2292","2292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US INFT HIPS R-T IMG LMTD STATIC NO MANIPULATION","30100049","CDM","402","RC","76886","HCPCS",,,"facility","inpatient",,,,"872","872",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US INFT HIPS R-T IMG LMTD STATIC NO MANIPULATION","30100049","CDM","402","RC","76886","HCPCS",,,"facility","outpatient",,,,"872","872",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US VASC ACCESS ADD ON","30100051","CDM","402","RC","76937","HCPCS",,,"facility","inpatient",,,,"1372","1372",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US VASC ACCESS ADD ON","30100051","CDM","402","RC","76937","HCPCS",,,"facility","outpatient",,,,"1372","1372",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US GDE PRNCHYML TISS ABLN","30100052","CDM","402","RC","76940","HCPCS",,,"facility","inpatient",,,,"1479","1479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US GDE PRNCHYML TISS ABLN","30100052","CDM","402","RC","76940","HCPCS",,,"facility","outpatient",,,,"1479","1479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US FETAL TRANSFUSION  IUT","30100053","CDM","402","RC","76941","HCPCS",,,"facility","inpatient",,,,"3802","3802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US FETAL TRANSFUSION  IUT","30100053","CDM","402","RC","76941","HCPCS",,,"facility","outpatient",,,,"3802","3802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US GUIDED NEEDLE PLACE","30100054","CDM","402","RC","76942","HCPCS",,,"facility","inpatient",,,,"1894","1894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US GUIDED NEEDLE PLACE","30100054","CDM","402","RC","76942","HCPCS",,,"facility","outpatient",,,,"1894","1894",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US VILLUS SAMPLING","30100055","CDM","402","RC","76945","HCPCS",,,"facility","inpatient",,,,"1318","1318",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US VILLUS SAMPLING","30100055","CDM","402","RC","76945","HCPCS",,,"facility","outpatient",,,,"1318","1318",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US AMNIOCENTESIS","30100056","CDM","402","RC","76946","HCPCS",,,"facility","inpatient",,,,"358","358",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US AMNIOCENTESIS","30100056","CDM","402","RC","76946","HCPCS",,,"facility","outpatient",,,,"358","358",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US GUIDE INTERSTITIAL THERAPY","30100057","CDM","402","RC","76965","HCPCS",,,"facility","inpatient",,,,"2148","2148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US GUIDE INTERSTITIAL THERAPY","30100057","CDM","402","RC","76965","HCPCS",,,"facility","outpatient",,,,"2148","2148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACHYMETRY UNILATERAL OR BILATERAL","30100060","CDM","402","RC","76514","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PACHYMETRY UNILATERAL OR BILATERAL","30100060","CDM","402","RC","76514","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OPHTH BIO ASCAN W IO LENS BIL","30100063","CDM","402","RC","76519","HCPCS",,,"facility","inpatient",,,,"749","749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OPHTH BIO ASCAN W IO LENS BIL","30100063","CDM","402","RC","76519","HCPCS",,,"facility","outpatient",,,,"749","749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ECHO FETAL FU REPEAT","30100066","CDM","402","RC","76826","HCPCS",,,"facility","inpatient",,,,"2034","2034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ECHO FETAL FU REPEAT","30100066","CDM","402","RC","76826","HCPCS",,,"facility","outpatient",,,,"2034","2034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US DOPPLER ECHO FETAL FU","30100067","CDM","402","RC","76828","HCPCS",,,"facility","inpatient",,,,"482","482",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US DOPPLER ECHO FETAL FU","30100067","CDM","402","RC","76828","HCPCS",,,"facility","outpatient",,,,"482","482",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US BX ENDOMYOCARDIAL","30100068","CDM","402","RC","76932","HCPCS",,,"facility","inpatient",,,,"1212","1212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US BX ENDOMYOCARDIAL","30100068","CDM","402","RC","76932","HCPCS",,,"facility","outpatient",,,,"1212","1212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OPHTH, B & QUANT A","30100070","CDM","402","RC","76510","HCPCS",,,"facility","inpatient",,,,"2558","2558",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US OPHTH, B & QUANT A","30100070","CDM","402","RC","76510","HCPCS",,,"facility","outpatient",,,,"2558","2558",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US LOCALIZE FB IN EYE","30100072","CDM","402","RC","76529","HCPCS",,,"facility","inpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US LOCALIZE FB IN EYE","30100072","CDM","402","RC","76529","HCPCS",,,"facility","outpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US COMPLETE JOINT REAL TIME W/IMAGE LT","30100082","CDM","402","RC","76881","HCPCS",,,"facility","inpatient",,,"LT","1299","1299",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US COMPLETE JOINT REAL TIME W/IMAGE LT","30100082","CDM","402","RC","76881","HCPCS",,,"facility","outpatient",,,"LT","1299","1299",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US COMPLETE JOINT REAL TIME W/IMAGE RT","30100083","CDM","402","RC","76881","HCPCS",,,"facility","inpatient",,,"RT","1299","1299",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US COMPLETE JOINT REAL TIME W/IMAGE RT","30100083","CDM","402","RC","76881","HCPCS",,,"facility","outpatient",,,"RT","1299","1299",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US LIMITED JOINT/FCL EVL REAL TIME W/IMAGE LT","30100084","CDM","402","RC","76882","HCPCS",,,"facility","inpatient",,,"LT","847","847",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US LIMITED JOINT/FCL EVL REAL TIME W/IMAGE LT","30100084","CDM","402","RC","76882","HCPCS",,,"facility","outpatient",,,"LT","847","847",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US LIMITED JOINT/FCL EVL REAL TIME W/IMAGE RT","30100085","CDM","402","RC","76882","HCPCS",,,"facility","inpatient",,,"RT","847","847",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US LIMITED JOINT/FCL EVL REAL TIME W/IMAGE RT","30100085","CDM","402","RC","76882","HCPCS",,,"facility","outpatient",,,"RT","847","847",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BX OR EXSN LYMPH NODE(S) OPEN DEEP AXILLARY","30100086","CDM","361","RC","38525","HCPCS",,,"facility","inpatient",,,,"12874","12874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX OR EXSN LYMPH NODE(S) OPEN DEEP AXILLARY","30100086","CDM","361","RC","38525","HCPCS",,,"facility","outpatient",,,,"12874","12874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERCUTANEOUS LIVER BIOPSY","30100087","CDM","361","RC","47000","HCPCS",,,"facility","inpatient",,,,"4749","4749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERCUTANEOUS LIVER BIOPSY","30100087","CDM","361","RC","47000","HCPCS",,,"facility","outpatient",,,,"4749","4749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US DRN W CATH PLACE PRC","30100090","CDM","402","RC","75989","HCPCS",,,"facility","inpatient",,,,"3144","3144",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US DRN W CATH PLACE PRC","30100090","CDM","402","RC","75989","HCPCS",,,"facility","outpatient",,,,"3144","3144",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSFUSION INTRAUTERINE FETAL","30100096","CDM","391","RC","36460","HCPCS",,,"facility","inpatient",,,,"1787","1787",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSFUSION INTRAUTERINE FETAL","30100096","CDM","391","RC","36460","HCPCS",,,"facility","outpatient",,,,"1787","1787",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US BREAST COMPLETE BI","30100112","CDM","402","RC","76641","HCPCS",,,"facility","inpatient",,,"50","1637","1637",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG US BREAST COMPLETE BI","30100112","CDM","402","RC","76641","HCPCS",,,"facility","outpatient",,,"50","1637","1637",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG US BREAST LIMITED BI","30100113","CDM","402","RC","76642","HCPCS",,,"facility","inpatient",,,"50","1298","1298",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG US BREAST LIMITED BI","30100113","CDM","402","RC","76642","HCPCS",,,"facility","outpatient",,,"50","1298","1298",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG US BREAST COMPLETE LT","30100114","CDM","402","RC","76641","HCPCS",,,"facility","inpatient",,,"LT","1092","1092",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US BREAST COMPLETE LT","30100114","CDM","402","RC","76641","HCPCS",,,"facility","outpatient",,,"LT","1092","1092",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US BREAST COMPLETE RT","30100115","CDM","402","RC","76641","HCPCS",,,"facility","inpatient",,,"RT","1092","1092",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US BREAST COMPLETE RT","30100115","CDM","402","RC","76641","HCPCS",,,"facility","outpatient",,,"RT","1092","1092",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US BREAST LIMITED LT","30100116","CDM","402","RC","76642","HCPCS",,,"facility","inpatient",,,"LT","865","865",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US BREAST LIMITED LT","30100116","CDM","402","RC","76642","HCPCS",,,"facility","outpatient",,,"LT","865","865",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG US BREAST LIMITED RT","30100117","CDM","402","RC","76642","HCPCS",,,"facility","inpatient",,,"RT","865","865",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG US BREAST LIMITED RT","30100117","CDM","402","RC","76642","HCPCS",,,"facility","outpatient",,,"RT","865","865",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PERQ DEV SOFT TISS 1ST IMAG","30100119","CDM","361","RC","10035","HCPCS",,,"facility","inpatient",,,,"2796","2796",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV SOFT TISS 1ST IMAG","30100119","CDM","361","RC","10035","HCPCS",,,"facility","outpatient",,,,"2796","2796",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV SOFT TISS ADD IMAG","30100120","CDM","361","RC","10036","HCPCS",,,"facility","inpatient",,,,"1881","1881",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ DEV SOFT TISS ADD IMAG","30100120","CDM","361","RC","10036","HCPCS",,,"facility","outpatient",,,,"1881","1881",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ABDL AORTA SCREEN AAA","30100123","CDM","402","RC","76706","HCPCS",,,"facility","inpatient",,,,"1021","1021",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ABDL AORTA SCREEN AAA","30100123","CDM","402","RC","76706","HCPCS",,,"facility","outpatient",,,,"1021","1021",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US PULSE ECHO BONE DENSITY","30100124","CDM","402","RC","0508T","HCPCS",,,"facility","inpatient",,,,"562","562",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US PULSE ECHO BONE DENSITY","30100124","CDM","402","RC","0508T","HCPCS",,,"facility","outpatient",,,,"562","562",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TARGET DYNM MICROBUBBLE 1ST LES","30100125","CDM","402","RC","76978","HCPCS",,,"facility","inpatient",,,,"803","803",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TARGET DYNM MICROBUBBLE 1ST LES","30100125","CDM","402","RC","76978","HCPCS",,,"facility","outpatient",,,,"803","803",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TARGET DYNM MICROBUBBLE EA ADD","30100126","CDM","402","RC","76979","HCPCS",,,"facility","inpatient",,,,"596","596",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US TARGET DYNM MICROBUBBLE EA ADD","30100126","CDM","402","RC","76979","HCPCS",,,"facility","outpatient",,,,"596","596",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ELASTOGRAPHY PARENCHYMA","30100127","CDM","402","RC","76981","HCPCS",,,"facility","inpatient",,,,"866","866",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ELASTOGRAPHY PARENCHYMA","30100127","CDM","402","RC","76981","HCPCS",,,"facility","outpatient",,,,"866","866",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ELASTOGRAPHY 1ST LES","30100128","CDM","402","RC","76982","HCPCS",,,"facility","inpatient",,,,"407","407",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ELASTOGRAPHY 1ST LES","30100128","CDM","402","RC","76982","HCPCS",,,"facility","outpatient",,,,"407","407",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ELASTOGRAPHY EA ADD","30100129","CDM","402","RC","76983","HCPCS",,,"facility","inpatient",,,,"407","407",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG US ELASTOGRAPHY EA ADD","30100129","CDM","402","RC","76983","HCPCS",,,"facility","outpatient",,,,"407","407",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DUPLX SCAN ARTL INFL&VEN O/F HEMO COMPL BI STD","30100130","CDM","402","RC","93985","HCPCS",,,"facility","inpatient",,,,"1407","1407",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DUPLX SCAN ARTL INFL&VEN O/F HEMO COMPL BI STD","30100130","CDM","402","RC","93985","HCPCS",,,"facility","outpatient",,,,"1407","1407",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DUPLX SCAN ARTL INFL&VEN O/F HEMO COMPL UNI STD","30100131","CDM","402","RC","93986","HCPCS",,,"facility","inpatient",,,,"626","626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DUPLX SCAN ARTL INFL&VEN O/F HEMO COMPL UNI STD","30100131","CDM","402","RC","93986","HCPCS",,,"facility","outpatient",,,,"626","626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX EXTRACRANIAL BILATERAL","30200001","CDM","921","RC","93880","HCPCS",,,"facility","inpatient",,,,"2747","2747",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX EXTRACRANIAL BILATERAL","30200001","CDM","921","RC","93880","HCPCS",,,"facility","outpatient",,,,"2747","2747",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI TRANSCRANIAL DOPPLER COMPLETE","30200003","CDM","921","RC","93886","HCPCS",,,"facility","inpatient",,,,"2556","2556",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI TRANSCRANIAL DOPPLER COMPLETE","30200003","CDM","921","RC","93886","HCPCS",,,"facility","outpatient",,,,"2556","2556",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI TRANSCRANIAL DOPPLER LIMITED","30200004","CDM","921","RC","93888","HCPCS",,,"facility","inpatient",,,,"2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI TRANSCRANIAL DOPPLER LIMITED","30200004","CDM","921","RC","93888","HCPCS",,,"facility","outpatient",,,,"2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI EXTREMITY ARTERIAL 1 LEVEL BILATERAL LTD","30200006","CDM","921","RC","93922","HCPCS",,,"facility","inpatient",,,,"1093","1093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI EXTREMITY ARTERIAL 1 LEVEL BILATERAL LTD","30200006","CDM","921","RC","93922","HCPCS",,,"facility","outpatient",,,,"1093","1093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI EXTREMITY ARTERIAL MULTIPLE BILATERAL","30200008","CDM","921","RC","93923","HCPCS",,,"facility","inpatient",,,,"1677","1677",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI EXTREMITY ARTERIAL MULTIPLE BILATERAL","30200008","CDM","921","RC","93923","HCPCS",,,"facility","outpatient",,,,"1677","1677",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI EXTREMITY LOW W STRESS","30200010","CDM","921","RC","93924","HCPCS",,,"facility","inpatient",,,,"2400","2400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI EXTREMITY LOW W STRESS","30200010","CDM","921","RC","93924","HCPCS",,,"facility","outpatient",,,,"2400","2400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX EXTREMITY LOW BILATERAL","30200011","CDM","921","RC","93925","HCPCS",,,"facility","inpatient",,,,"2759","2759",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX EXTREMITY LOW BILATERAL","30200011","CDM","921","RC","93925","HCPCS",,,"facility","outpatient",,,,"2759","2759",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX EXTREMITY UPPER BILATERAL","30200013","CDM","921","RC","93930","HCPCS",,,"facility","inpatient",,,,"2842","2842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX EXTREMITY UPPER BILATERAL","30200013","CDM","921","RC","93930","HCPCS",,,"facility","outpatient",,,,"2842","2842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX EXTREMITY VEINS BILATERAL","30200016","CDM","921","RC","93970","HCPCS",,,"facility","inpatient",,,,"2871","2871",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX EXTREMITY VEINS BILATERAL","30200016","CDM","921","RC","93970","HCPCS",,,"facility","outpatient",,,,"2871","2871",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX ABDOMEN PELVIS COMPLETE","30200018","CDM","921","RC","93975","HCPCS",,,"facility","inpatient",,,,"3124","3124",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX ABDOMEN PELVIS COMPLETE","30200018","CDM","921","RC","93975","HCPCS",,,"facility","outpatient",,,,"3124","3124",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX ABDOMEN PELVIC LTD","30200019","CDM","921","RC","93976","HCPCS",,,"facility","inpatient",,,,"2111","2111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DUPLEX ABDOMEN PELVIC LTD","30200019","CDM","921","RC","93976","HCPCS",,,"facility","outpatient",,,,"2111","2111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI AORTA IVC ILIAC COMPLETE","30200020","CDM","921","RC","93978","HCPCS",,,"facility","inpatient",,,,"2413","2413",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI AORTA IVC ILIAC COMPLETE","30200020","CDM","921","RC","93978","HCPCS",,,"facility","outpatient",,,,"2413","2413",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI AORTA IVC ILIAC LIMITED","30200021","CDM","921","RC","93979","HCPCS",,,"facility","inpatient",,,,"1654","1654",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI AORTA IVC ILIAC LIMITED","30200021","CDM","921","RC","93979","HCPCS",,,"facility","outpatient",,,,"1654","1654",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI PENILE VESSELS COMPLETE","30200022","CDM","921","RC","93980","HCPCS",,,"facility","inpatient",,,,"2069","2069",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI PENILE VESSELS COMPLETE","30200022","CDM","921","RC","93980","HCPCS",,,"facility","outpatient",,,,"2069","2069",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DIALYSIS ACCESS","30200024","CDM","921","RC","93990","HCPCS",,,"facility","inpatient",,,,"1610","1610",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI DIALYSIS ACCESS","30200024","CDM","921","RC","93990","HCPCS",,,"facility","outpatient",,,,"1610","1610",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI TCD EMBOLI DETECT WO/IJ","30200027","CDM","921","RC","93892","HCPCS",,,"facility","inpatient",,,,"4034","4034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI TCD EMBOLI DETECT WO/IJ","30200027","CDM","921","RC","93892","HCPCS",,,"facility","outpatient",,,,"4034","4034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI CAROTID INTIMA ATHEROMA EVAL BI","30200029","CDM","921","RC","93895","HCPCS",,,"facility","inpatient",,,"GY","2305","2305",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG NI CAROTID INTIMA ATHEROMA EVAL BI","30200029","CDM","921","RC","93895","HCPCS",,,"facility","outpatient",,,"GY","2305","2305",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG NI DUPLEX EXT LOW UNI LT","30200102","CDM","921","RC","93926","HCPCS",,,"facility","inpatient",,,"LT","1845","1845",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NI DUPLEX EXT LOW UNI LT","30200102","CDM","921","RC","93926","HCPCS",,,"facility","outpatient",,,"LT","1845","1845",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NI DUPLEX EXT LOW UNI RT","30200103","CDM","921","RC","93926","HCPCS",,,"facility","inpatient",,,"RT","1845","1845",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NI DUPLEX EXT LOW UNI RT","30200103","CDM","921","RC","93926","HCPCS",,,"facility","outpatient",,,"RT","1845","1845",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NI DUPLEX EXT UPP UNI LT","30200104","CDM","921","RC","93931","HCPCS",,,"facility","inpatient",,,"LT","1942","1942",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NI DUPLEX EXT UPP UNI LT","30200104","CDM","921","RC","93931","HCPCS",,,"facility","outpatient",,,"LT","1942","1942",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NI DUPLEX EXT UPP UNI RT","30200105","CDM","921","RC","93931","HCPCS",,,"facility","inpatient",,,"RT","1942","1942",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NI DUPLEX EXT UPP UNI RT","30200105","CDM","921","RC","93931","HCPCS",,,"facility","outpatient",,,"RT","1942","1942",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NI DUPLX EXT VEINS UNI LT","30200106","CDM","921","RC","93971","HCPCS",,,"facility","inpatient",,,"LT","2046","2046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NI DUPLX EXT VEINS UNI LT","30200106","CDM","921","RC","93971","HCPCS",,,"facility","outpatient",,,"LT","2046","2046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NI DUPLX EXT VEINS UNI RT","30200107","CDM","921","RC","93971","HCPCS",,,"facility","inpatient",,,"RT","2046","2046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NI DUPLX EXT VEINS UNI RT","30200107","CDM","921","RC","93971","HCPCS",,,"facility","outpatient",,,"RT","2046","2046",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NI DUPLEX EXTRCRAN UNI LT","30200108","CDM","921","RC","93882","HCPCS",,,"facility","inpatient",,,"LT","1608","1608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NI DUPLEX EXTRCRAN UNI LT","30200108","CDM","921","RC","93882","HCPCS",,,"facility","outpatient",,,"LT","1468","1468",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG NI DUPLEX EXTRCRAN UNI RT","30200109","CDM","921","RC","93882","HCPCS",,,"facility","inpatient",,,"RT","1608","1608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NI DUPLEX EXTRCRAN UNI RT","30200109","CDM","921","RC","93882","HCPCS",,,"facility","outpatient",,,"RT","1468","1468",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG NI TCD STD ICR ART VEN-ART SHNT","30200112","CDM","921","RC","93893","HCPCS",,,"facility","inpatient",,,,"5488","5488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NI TCD STD ICR ART VEN-ART SHNT","30200112","CDM","921","RC","93893","HCPCS",,,"facility","outpatient",,,,"5488","5488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MR TEMPOROMANDIBULAR JOINTS","30300002","CDM","610","RC","70336","HCPCS",,,"facility","inpatient",,,,"4939","4939",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MR TEMPOROMANDIBULAR JOINTS","30300002","CDM","610","RC","70336","HCPCS",,,"facility","outpatient",,,,"4939","4939",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ORBIT AND FACE AND NECK WO CONTR","30300003","CDM","610","RC","70540","HCPCS",,,"facility","inpatient",,,,"4351","4351",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ORBIT AND FACE AND NECK WO CONTR","30300003","CDM","610","RC","70540","HCPCS",,,"facility","outpatient",,,,"4351","4351",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ORBIT AND FACE AND NECK W CONTR","30300004","CDM","610","RC","70542","HCPCS",,,"facility","inpatient",,,,"8245","8245",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ORBIT AND FACE AND NECK W CONTR","30300004","CDM","610","RC","70542","HCPCS",,,"facility","outpatient",,,,"8245","8245",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ORBIT AND FACE AND NECK W AND WO CONTR","30300005","CDM","610","RC","70543","HCPCS",,,"facility","inpatient",,,,"7992","7992",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ORBIT AND FACE AND NECK W AND WO CONTR","30300005","CDM","610","RC","70543","HCPCS",,,"facility","outpatient",,,,"7992","7992",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA HEAD WO CONTR","30300006","CDM","615","RC","70544","HCPCS",,,"facility","inpatient",,,,"5677","5677",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA HEAD WO CONTR","30300006","CDM","615","RC","70544","HCPCS",,,"facility","outpatient",,,,"5677","5677",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA HEAD W CONTR","30300007","CDM","615","RC","70545","HCPCS",,,"facility","inpatient",,,,"6437","6437",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA HEAD W CONTR","30300007","CDM","615","RC","70545","HCPCS",,,"facility","outpatient",,,,"6437","6437",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA HEAD W AND WO CONTR","30300008","CDM","615","RC","70546","HCPCS",,,"facility","inpatient",,,,"7839","7839",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA HEAD W AND WO CONTR","30300008","CDM","615","RC","70546","HCPCS",,,"facility","outpatient",,,,"7839","7839",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA NECK WO CONTR","30300009","CDM","615","RC","70547","HCPCS",,,"facility","inpatient",,,,"5464","5464",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA NECK WO CONTR","30300009","CDM","615","RC","70547","HCPCS",,,"facility","outpatient",,,,"5464","5464",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA NECK W CONTR","30300010","CDM","615","RC","70548","HCPCS",,,"facility","inpatient",,,,"5978","5978",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA NECK W CONTR","30300010","CDM","615","RC","70548","HCPCS",,,"facility","outpatient",,,,"5978","5978",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA NECK W AND WO CONTR","30300011","CDM","615","RC","70549","HCPCS",,,"facility","inpatient",,,,"8824","8824",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA NECK W AND WO CONTR","30300011","CDM","615","RC","70549","HCPCS",,,"facility","outpatient",,,,"8824","8824",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BRAIN W STEM WO CONTR","30300012","CDM","611","RC","70551","HCPCS",,,"facility","inpatient",,,,"5481","5481",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BRAIN W STEM WO CONTR","30300012","CDM","611","RC","70551","HCPCS",,,"facility","outpatient",,,,"5481","5481",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BRAIN W STEM W CONTR","30300013","CDM","611","RC","70552","HCPCS",,,"facility","inpatient",,,,"7192","7192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BRAIN W STEM W CONTR","30300013","CDM","611","RC","70552","HCPCS",,,"facility","outpatient",,,,"7192","7192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BRAIN W STEM W AND WO CONTR","30300014","CDM","611","RC","70553","HCPCS",,,"facility","inpatient",,,,"8334","8334",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BRAIN W STEM W AND WO CONTR","30300014","CDM","611","RC","70553","HCPCS",,,"facility","outpatient",,,,"8334","8334",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CHEST WO CONTR","30300018","CDM","610","RC","71550","HCPCS",,,"facility","inpatient",,,,"4588","4588",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CHEST WO CONTR","30300018","CDM","610","RC","71550","HCPCS",,,"facility","outpatient",,,,"4588","4588",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CHEST W CONTR","30300019","CDM","610","RC","71551","HCPCS",,,"facility","inpatient",,,,"6294","6294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CHEST W CONTR","30300019","CDM","610","RC","71551","HCPCS",,,"facility","outpatient",,,,"6294","6294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CHEST W AND WO CONTR","30300020","CDM","610","RC","71552","HCPCS",,,"facility","inpatient",,,,"8053","8053",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CHEST W AND WO CONTR","30300020","CDM","610","RC","71552","HCPCS",,,"facility","outpatient",,,,"8053","8053",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE CERV WO CONTR","30300021","CDM","612","RC","72141","HCPCS",,,"facility","inpatient",,,,"5265","5265",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE CERV WO CONTR","30300021","CDM","612","RC","72141","HCPCS",,,"facility","outpatient",,,,"5265","5265",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE CERV W CONTR","30300022","CDM","612","RC","72142","HCPCS",,,"facility","inpatient",,,,"6480","6480",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE CERV W CONTR","30300022","CDM","612","RC","72142","HCPCS",,,"facility","outpatient",,,,"6480","6480",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE THOR WO CONTR","30300023","CDM","612","RC","72146","HCPCS",,,"facility","inpatient",,,,"5458","5458",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE THOR WO CONTR","30300023","CDM","612","RC","72146","HCPCS",,,"facility","outpatient",,,,"5458","5458",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE THOR W CONTR","30300024","CDM","612","RC","72147","HCPCS",,,"facility","inpatient",,,,"6508","6508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE THOR W CONTR","30300024","CDM","612","RC","72147","HCPCS",,,"facility","outpatient",,,,"6508","6508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE LUMB WO CONTR","30300025","CDM","612","RC","72148","HCPCS",,,"facility","inpatient",,,,"5217","5217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE LUMB WO CONTR","30300025","CDM","612","RC","72148","HCPCS",,,"facility","outpatient",,,,"5217","5217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE LUMB W CONTR","30300026","CDM","612","RC","72149","HCPCS",,,"facility","inpatient",,,,"8076","8076",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE LUMB W CONTR","30300026","CDM","612","RC","72149","HCPCS",,,"facility","outpatient",,,,"8076","8076",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE CERV W AND WO CONTR","30300027","CDM","612","RC","72156","HCPCS",,,"facility","inpatient",,,,"8560","8560",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE CERV W AND WO CONTR","30300027","CDM","612","RC","72156","HCPCS",,,"facility","outpatient",,,,"8560","8560",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE THOR W AND WO CONTR","30300028","CDM","612","RC","72157","HCPCS",,,"facility","inpatient",,,,"8406","8406",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE THOR W AND WO CONTR","30300028","CDM","612","RC","72157","HCPCS",,,"facility","outpatient",,,,"8406","8406",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE LUMB W AND WO CONTR","30300029","CDM","612","RC","72158","HCPCS",,,"facility","inpatient",,,,"8441","8441",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI SPINE LUMB W AND WO CONTR","30300029","CDM","612","RC","72158","HCPCS",,,"facility","outpatient",,,,"8441","8441",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI PELVIS WO CONTR","30300031","CDM","610","RC","72195","HCPCS",,,"facility","inpatient",,,,"5735","5735",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI PELVIS WO CONTR","30300031","CDM","610","RC","72195","HCPCS",,,"facility","outpatient",,,,"5735","5735",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI PELVIS W CONTR","30300032","CDM","610","RC","72196","HCPCS",,,"facility","inpatient",,,,"5220","5220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI PELVIS W CONTR","30300032","CDM","610","RC","72196","HCPCS",,,"facility","outpatient",,,,"5220","5220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI PELVIS W AND WO CONTR","30300033","CDM","610","RC","72197","HCPCS",,,"facility","inpatient",,,,"8535","8535",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI PELVIS W AND WO CONTR","30300033","CDM","610","RC","72197","HCPCS",,,"facility","outpatient",,,,"8535","8535",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI EXTREM UPPER NO JOINT WO CONTR BIL","30300034","CDM","610","RC","73218","HCPCS",,,"facility","inpatient",,,"50","6684","6684",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER NO JOINT WO CONTR BIL","30300034","CDM","610","RC","73218","HCPCS",,,"facility","outpatient",,,"50","6684","6684",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER NO JOINT WO CONTR LT","30300035","CDM","610","RC","73218","HCPCS",,,"facility","inpatient",,,"LT","4456","4456",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT WO CONTR LT","30300035","CDM","610","RC","73218","HCPCS",,,"facility","outpatient",,,"LT","4456","4456",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT WO CONTR RT","30300036","CDM","610","RC","73218","HCPCS",,,"facility","inpatient",,,"RT","4456","4456",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT WO CONTR RT","30300036","CDM","610","RC","73218","HCPCS",,,"facility","outpatient",,,"RT","4456","4456",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT W CONTR BIL","30300037","CDM","610","RC","73219","HCPCS",,,"facility","inpatient",,,"50","5882","5882",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER NO JOINT W CONTR BIL","30300037","CDM","610","RC","73219","HCPCS",,,"facility","outpatient",,,"50","5882","5882",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER NO JOINT W CONTR LT","30300038","CDM","610","RC","73219","HCPCS",,,"facility","inpatient",,,"LT","3921","3921",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT W CONTR LT","30300038","CDM","610","RC","73219","HCPCS",,,"facility","outpatient",,,"LT","3921","3921",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT W CONTR RT","30300039","CDM","610","RC","73219","HCPCS",,,"facility","inpatient",,,"RT","3921","3921",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT W CONTR RT","30300039","CDM","610","RC","73219","HCPCS",,,"facility","outpatient",,,"RT","3921","3921",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT W AND WO CONTR BIL","30300040","CDM","610","RC","73220","HCPCS",,,"facility","inpatient",,,"50","10300","10300",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER NO JOINT W AND WO CONTR BIL","30300040","CDM","610","RC","73220","HCPCS",,,"facility","outpatient",,,"50","10300","10300",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER NO JOINT W AND WO CONTR LT","30300041","CDM","610","RC","73220","HCPCS",,,"facility","inpatient",,,"LT","6867","6867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT W AND WO CONTR LT","30300041","CDM","610","RC","73220","HCPCS",,,"facility","outpatient",,,"LT","6867","6867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT W AND WO CONTR RT","30300042","CDM","610","RC","73220","HCPCS",,,"facility","inpatient",,,"RT","6867","6867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER NO JOINT W AND WO CONTR RT","30300042","CDM","610","RC","73220","HCPCS",,,"facility","outpatient",,,"RT","6867","6867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER JOINT WO CONTR BIL","30300043","CDM","610","RC","73221","HCPCS",,,"facility","inpatient",,,"50","7291","7291",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER JOINT WO CONTR BIL","30300043","CDM","610","RC","73221","HCPCS",,,"facility","outpatient",,,"50","7291","7291",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER JOINT WO CONTR LT","30300044","CDM","610","RC","73221","HCPCS",,,"facility","inpatient",,,"LT","4860","4860",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER JOINT WO CONTR LT","30300044","CDM","610","RC","73221","HCPCS",,,"facility","outpatient",,,"LT","4860","4860",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER JOINT WO CONTR RT","30300045","CDM","610","RC","73221","HCPCS",,,"facility","inpatient",,,"RT","4860","4860",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER JOINT WO CONTR RT","30300045","CDM","610","RC","73221","HCPCS",,,"facility","outpatient",,,"RT","4860","4860",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER JOINT W CONTR BIL","30300046","CDM","610","RC","73222","HCPCS",,,"facility","inpatient",,,"50","7576","7576",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER JOINT W CONTR BIL","30300046","CDM","610","RC","73222","HCPCS",,,"facility","outpatient",,,"50","7576","7576",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER JOINT W CONTR LT","30300047","CDM","610","RC","73222","HCPCS",,,"facility","inpatient",,,"LT","5051","5051",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER JOINT W CONTR LT","30300047","CDM","610","RC","73222","HCPCS",,,"facility","outpatient",,,"LT","5051","5051",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER JOINT W CONTR RT","30300048","CDM","610","RC","73222","HCPCS",,,"facility","inpatient",,,"RT","5051","5051",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER JOINT W CONTR RT","30300048","CDM","610","RC","73222","HCPCS",,,"facility","outpatient",,,"RT","5051","5051",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER JOINT W AND WO CONTR BIL","30300049","CDM","610","RC","73223","HCPCS",,,"facility","inpatient",,,"50","10739","10739",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER JOINT W AND WO CONTR BIL","30300049","CDM","610","RC","73223","HCPCS",,,"facility","outpatient",,,"50","10739","10739",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM UPPER JOINT W AND WO CONTR LT","30300050","CDM","610","RC","73223","HCPCS",,,"facility","inpatient",,,"LT","7159","7159",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER JOINT W AND WO CONTR LT","30300050","CDM","610","RC","73223","HCPCS",,,"facility","outpatient",,,"LT","7159","7159",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM UPPER JOINT W AND WO CONTR RT","30300051","CDM","610","RC","73223","HCPCS",,,"facility","inpatient",,,"RT","7159","7159",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM UPPER JOINT W AND WO CONTR RT","30300051","CDM","610","RC","73223","HCPCS",,,"facility","outpatient",,,"RT","7159","7159",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER WO CONTR BIL","30300055","CDM","610","RC","73718","HCPCS",,,"facility","inpatient",,,"50","6744","6744",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER WO CONTR BIL","30300055","CDM","610","RC","73718","HCPCS",,,"facility","outpatient",,,"50","6744","6744",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER WO CONTR LT","30300056","CDM","610","RC","73718","HCPCS",,,"facility","inpatient",,,"LT","4496","4496",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER WO CONTR LT","30300056","CDM","610","RC","73718","HCPCS",,,"facility","outpatient",,,"LT","4496","4496",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER WO CONTR RT","30300057","CDM","610","RC","73718","HCPCS",,,"facility","inpatient",,,"RT","4496","4496",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER WO CONTR RT","30300057","CDM","610","RC","73718","HCPCS",,,"facility","outpatient",,,"RT","4496","4496",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER NO JOINT W CONTR BIL","30300058","CDM","610","RC","73719","HCPCS",,,"facility","inpatient",,,"50","10124","10124",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER NO JOINT W CONTR BIL","30300058","CDM","610","RC","73719","HCPCS",,,"facility","outpatient",,,"50","10124","10124",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER NO JOINT W CONTR LT","30300059","CDM","610","RC","73719","HCPCS",,,"facility","inpatient",,,"LT","6749","6749",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER NO JOINT W CONTR LT","30300059","CDM","610","RC","73719","HCPCS",,,"facility","outpatient",,,"LT","6749","6749",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER NO JOINT W CONTR RT","30300060","CDM","610","RC","73719","HCPCS",,,"facility","inpatient",,,"RT","6749","6749",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER NO JOINT W CONTR RT","30300060","CDM","610","RC","73719","HCPCS",,,"facility","outpatient",,,"RT","6749","6749",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER W AND WO CONTR BIL","30300061","CDM","610","RC","73720","HCPCS",,,"facility","inpatient",,,"50","10040","10040",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER W AND WO CONTR BIL","30300061","CDM","610","RC","73720","HCPCS",,,"facility","outpatient",,,"50","10040","10040",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER W AND WO CONTR LT","30300062","CDM","610","RC","73720","HCPCS",,,"facility","inpatient",,,"LT","6693","6693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER W AND WO CONTR LT","30300062","CDM","610","RC","73720","HCPCS",,,"facility","outpatient",,,"LT","6693","6693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER W AND WO CONTR RT","30300063","CDM","610","RC","73720","HCPCS",,,"facility","inpatient",,,"RT","6693","6693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER W AND WO CONTR RT","30300063","CDM","610","RC","73720","HCPCS",,,"facility","outpatient",,,"RT","6693","6693",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER JOINT WO CONTR BIL","30300064","CDM","610","RC","73721","HCPCS",,,"facility","inpatient",,,"50","7464","7464",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER JOINT WO CONTR BIL","30300064","CDM","610","RC","73721","HCPCS",,,"facility","outpatient",,,"50","7464","7464",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER JOINT WO CONTR LT","30300065","CDM","610","RC","73721","HCPCS",,,"facility","inpatient",,,"LT","4976","4976",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER JOINT WO CONTR LT","30300065","CDM","610","RC","73721","HCPCS",,,"facility","outpatient",,,"LT","4976","4976",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER JOINT WO CONTR RT","30300066","CDM","610","RC","73721","HCPCS",,,"facility","inpatient",,,"RT","4976","4976",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER JOINT WO CONTR RT","30300066","CDM","610","RC","73721","HCPCS",,,"facility","outpatient",,,"RT","4976","4976",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER JOINT W CONTR BIL","30300067","CDM","610","RC","73722","HCPCS",,,"facility","inpatient",,,"50","7678","7678",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER JOINT W CONTR BIL","30300067","CDM","610","RC","73722","HCPCS",,,"facility","outpatient",,,"50","7678","7678",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER JOINT W CONTR LT","30300068","CDM","610","RC","73722","HCPCS",,,"facility","inpatient",,,"LT","5118","5118",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER JOINT W CONTR LT","30300068","CDM","610","RC","73722","HCPCS",,,"facility","outpatient",,,"LT","5118","5118",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER JOINT W CONTR RT","30300069","CDM","610","RC","73722","HCPCS",,,"facility","inpatient",,,"RT","5118","5118",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER JOINT W CONTR RT","30300069","CDM","610","RC","73722","HCPCS",,,"facility","outpatient",,,"RT","5118","5118",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER JOINT W AND WO CONTR BIL","30300070","CDM","610","RC","73723","HCPCS",,,"facility","inpatient",,,"50","11300","11300",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER JOINT W AND WO CONTR BIL","30300070","CDM","610","RC","73723","HCPCS",,,"facility","outpatient",,,"50","11300","11300",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRI EXTREM LOWER JOINT W AND WO CONTR LT","30300071","CDM","610","RC","73723","HCPCS",,,"facility","inpatient",,,"LT","7534","7534",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER JOINT W AND WO CONTR LT","30300071","CDM","610","RC","73723","HCPCS",,,"facility","outpatient",,,"LT","7534","7534",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRI EXTREM LOWER JOINT W AND WO CONTR RT","30300072","CDM","610","RC","73723","HCPCS",,,"facility","inpatient",,,"RT","7534","7534",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI EXTREM LOWER JOINT W AND WO CONTR RT","30300072","CDM","610","RC","73723","HCPCS",,,"facility","outpatient",,,"RT","7534","7534",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI ABDOMEN WO CONTR","30300073","CDM","610","RC","74181","HCPCS",,,"facility","inpatient",,,,"5540","5540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ABDOMEN WO CONTR","30300073","CDM","610","RC","74181","HCPCS",,,"facility","outpatient",,,,"5540","5540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ABDOMEN W CONTR","30300074","CDM","610","RC","74182","HCPCS",,,"facility","inpatient",,,,"5386","5386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ABDOMEN W CONTR","30300074","CDM","610","RC","74182","HCPCS",,,"facility","outpatient",,,,"5386","5386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ABDOMEN W AND WO CONTR","30300075","CDM","610","RC","74183","HCPCS",,,"facility","inpatient",,,,"7712","7712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ABDOMEN W AND WO CONTR","30300075","CDM","610","RC","74183","HCPCS",,,"facility","outpatient",,,,"7712","7712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MR 3D RENDERING INTERP & POSTPROCESS SUPERVISION","30300080","CDM","610","RC","76376","HCPCS",,,"facility","inpatient",,,,"1312","1312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MR 3D RENDERING INTERP & POSTPROCESS SUPERVISION","30300080","CDM","610","RC","76376","HCPCS",,,"facility","outpatient",,,,"1312","1312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MR SPECTROSCOPY","30300082","CDM","610","RC","76390","HCPCS",,,"facility","inpatient",,,,"5525","5525",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MR SPECTROSCOPY","30300082","CDM","610","RC","76390","HCPCS",,,"facility","outpatient",,,,"5525","5525",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI GUIDED NEEDLE PLACEMENT","30300084","CDM","610","RC","77021","HCPCS",,,"facility","inpatient",,,,"5581","5581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI GUIDED NEEDLE PLACEMENT","30300084","CDM","610","RC","77021","HCPCS",,,"facility","outpatient",,,,"5581","5581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA ABD W CON","30300085","CDM","618","RC","C8900","HCPCS",,,"facility","inpatient",,,,"4415","4415",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA ABD W CON","30300085","CDM","618","RC","C8900","HCPCS",,,"facility","outpatient",,,,"4415","4415",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA ABD W/O CON","30300086","CDM","618","RC","C8901","HCPCS",,,"facility","inpatient",,,,"5017","5017",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA ABD W/O CON","30300086","CDM","618","RC","C8901","HCPCS",,,"facility","outpatient",,,,"5017","5017",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA ABD W-W/O CON","30300087","CDM","618","RC","C8902","HCPCS",,,"facility","inpatient",,,,"6953","6953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA ABD W-W/O CON","30300087","CDM","618","RC","C8902","HCPCS",,,"facility","outpatient",,,,"6953","6953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA CHEST W/O CON","30300095","CDM","618","RC","C8910","HCPCS",,,"facility","inpatient",,,,"5951","5951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA CHEST W/O CON","30300095","CDM","618","RC","C8910","HCPCS",,,"facility","outpatient",,,,"5951","5951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA CHEST W-W/O CON","30300096","CDM","618","RC","C8911","HCPCS",,,"facility","inpatient",,,,"7678","7678",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA CHEST W-W/O CON","30300096","CDM","618","RC","C8911","HCPCS",,,"facility","outpatient",,,,"7678","7678",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA EXT LOW W CON BI","30300097","CDM","616","RC","C8912","HCPCS",,,"facility","inpatient",,,"50","7893","7893",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRA EXT LOW W CON BI","30300097","CDM","616","RC","C8912","HCPCS",,,"facility","outpatient",,,"50","7893","7893",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRA EXT LOW W/O CON BI","30300098","CDM","616","RC","C8913","HCPCS",,,"facility","inpatient",,,"50","6302","6302",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRA EXT LOW W/O CON BI","30300098","CDM","616","RC","C8913","HCPCS",,,"facility","outpatient",,,"50","6302","6302",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG MRA PELVIS W CON","30300100","CDM","618","RC","C8918","HCPCS",,,"facility","inpatient",,,,"4134","4134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA PELVIS W CON","30300100","CDM","618","RC","C8918","HCPCS",,,"facility","outpatient",,,,"4134","4134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA PELVIS W/O CON","30300101","CDM","618","RC","C8919","HCPCS",,,"facility","inpatient",,,,"3390","3390",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA PELVIS W/O CON","30300101","CDM","618","RC","C8919","HCPCS",,,"facility","outpatient",,,,"3390","3390",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA PELVIS W-W/O CON","30300102","CDM","618","RC","C8920","HCPCS",,,"facility","inpatient",,,,"8875","8875",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA PELVIS W-W/O CON","30300102","CDM","618","RC","C8920","HCPCS",,,"facility","outpatient",,,,"8875","8875",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CARD MORPH WO CON","30300105","CDM","610","RC","75557","HCPCS",,,"facility","inpatient",,,,"5936","5936",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CARD MORPH WO CON","30300105","CDM","610","RC","75557","HCPCS",,,"facility","outpatient",,,,"5936","5936",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CARD MORPH W-W/O","30300109","CDM","614","RC","75561","HCPCS",,,"facility","inpatient",,,,"7233","7233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CARD MORPH W-W/O","30300109","CDM","614","RC","75561","HCPCS",,,"facility","outpatient",,,,"7233","7233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CARD W/STRSS W-WO","30300111","CDM","610","RC","75563","HCPCS",,,"facility","inpatient",,,,"8346","8346",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CARD W/STRSS W-WO","30300111","CDM","610","RC","75563","HCPCS",,,"facility","outpatient",,,,"8346","8346",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA UPPER EXT W/O CON RT","30300135","CDM","618","RC","C8935","HCPCS",,,"facility","inpatient",,,"RT","5913","5913",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRA UPPER EXT W/O CON RT","30300135","CDM","618","RC","C8935","HCPCS",,,"facility","outpatient",,,"RT","5913","5913",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRA UPPER EXT W-WO CON","30300136","CDM","618","RC","C8936","HCPCS",,,"facility","inpatient",,,,"6143","6143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA UPPER EXT W-WO CON","30300136","CDM","618","RC","C8936","HCPCS",,,"facility","outpatient",,,,"6143","6143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MR 3D RENDERING INTERP&POSTPROC DIF WORK STATION","30300137","CDM","610","RC","76377","HCPCS",,,"facility","inpatient",,,,"2034","2034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MR 3D RENDERING INTERP&POSTPROC DIF WORK STATION","30300137","CDM","610","RC","76377","HCPCS",,,"facility","outpatient",,,,"2034","2034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA SPINAL CANAL W-WO CON","30300145","CDM","618","RC","C8933","HCPCS",,,"facility","inpatient",,,,"5266","5266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA SPINAL CANAL W-WO CON","30300145","CDM","618","RC","C8933","HCPCS",,,"facility","outpatient",,,,"5266","5266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRA EXT LOW W-W/O CON LT","30300152","CDM","616","RC","C8914","HCPCS",,,"facility","inpatient",,,"LT","7324","7324",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRA EXT LOW W-W/O CON LT","30300152","CDM","616","RC","C8914","HCPCS",,,"facility","outpatient",,,"LT","7324","7324",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRA EXT LOW W-W/O CON RT","30300153","CDM","616","RC","C8914","HCPCS",,,"facility","inpatient",,,"RT","7324","7324",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRA EXT LOW W-W/O CON RT","30300153","CDM","616","RC","C8914","HCPCS",,,"facility","outpatient",,,"RT","7324","7324",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRA EXT LOW W CON LT","30300154","CDM","616","RC","C8912","HCPCS",,,"facility","inpatient",,,"LT","5262","5262",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRA EXT LOW W CON LT","30300154","CDM","616","RC","C8912","HCPCS",,,"facility","outpatient",,,"LT","5262","5262",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRA EXT LOW W CON RT","30300155","CDM","616","RC","C8912","HCPCS",,,"facility","inpatient",,,"RT","5262","5262",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRA EXT LOW W CON RT","30300155","CDM","616","RC","C8912","HCPCS",,,"facility","outpatient",,,"RT","5262","5262",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRA EXT LOW W/O CON LT","30300156","CDM","616","RC","C8913","HCPCS",,,"facility","inpatient",,,"LT","4201","4201",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRA EXT LOW W/O CON LT","30300156","CDM","616","RC","C8913","HCPCS",,,"facility","outpatient",,,"LT","4201","4201",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG MRA EXT LOW W/O CON RT","30300157","CDM","616","RC","C8913","HCPCS",,,"facility","inpatient",,,"RT","4201","4201",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRA EXT LOW W/O CON RT","30300157","CDM","616","RC","C8913","HCPCS",,,"facility","outpatient",,,"RT","4201","4201",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG MRI FETAL SINGLE/1ST GESTATION","30300175","CDM","610","RC","74712","HCPCS",,,"facility","inpatient",,,,"1508","1508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI FETAL SINGLE/1ST GESTATION","30300175","CDM","610","RC","74712","HCPCS",,,"facility","outpatient",,,,"1508","1508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ELASTOGRAPHY","30300176","CDM","610","RC","76391","HCPCS",,,"facility","inpatient",,,,"975","975",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI ELASTOGRAPHY","30300176","CDM","610","RC","76391","HCPCS",,,"facility","outpatient",,,,"975","975",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST W/O CONTRAST RT","30300177","CDM","610","RC","77046","HCPCS",,,"facility","inpatient",,,,"4129","4129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST W/O CONTRAST RT","30300177","CDM","610","RC","77046","HCPCS",,,"facility","outpatient",,,,"4129","4129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST W/O CONTRAST BILAT","30300178","CDM","610","RC","77047","HCPCS",,,"facility","inpatient",,,,"4205","4205",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST W/O CONTRAST BILAT","30300178","CDM","610","RC","77047","HCPCS",,,"facility","outpatient",,,,"4205","4205",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST UNI WO/W CONTRAST W OR WO CAD LT","30300179","CDM","610","RC","C8905","HCPCS",,,"facility","inpatient",,,,"6493","6493",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST UNI WO/W CONTRAST W OR WO CAD LT","30300179","CDM","610","RC","C8905","HCPCS",,,"facility","outpatient",,,,"6493","6493",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST BIL WO/W CONTRAST W OR WO CAD","30300180","CDM","610","RC","C8908","HCPCS",,,"facility","inpatient",,,,"6731","6731",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST BIL WO/W CONTRAST W OR WO CAD","30300180","CDM","610","RC","C8908","HCPCS",,,"facility","outpatient",,,,"6731","6731",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST CAD","30300181","CDM","610","RC","C8937","HCPCS",,,"facility","inpatient",,,,"938","938",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST CAD","30300181","CDM","610","RC","C8937","HCPCS",,,"facility","outpatient",,,,"938","938",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST W/O CONTRAST LT","30300182","CDM","610","RC","77046","HCPCS",,,"facility","inpatient",,,,"4129","4129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST W/O CONTRAST LT","30300182","CDM","610","RC","77046","HCPCS",,,"facility","outpatient",,,,"4129","4129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST UNI WO/W CONTRAST W OR WO CAD RT","30300183","CDM","610","RC","C8905","HCPCS",,,"facility","inpatient",,,,"6493","6493",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI BREAST UNI WO/W CONTRAST W OR WO CAD RT","30300183","CDM","610","RC","C8905","HCPCS",,,"facility","outpatient",,,,"6493","6493",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI QUAN MRI ALYS BRN W/O DX MRI","30300200","CDM","610","RC","0865T","HCPCS",,,"facility","inpatient",,,,"4052","4052",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI QUAN MRI ALYS BRN W/O DX MRI","30300200","CDM","610","RC","0865T","HCPCS",,,"facility","outpatient",,,,"4052","4052",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI QUAN MRI ALYS BRN W/DX MRI","30300201","CDM","610","RC","0866T","HCPCS",,,"facility","inpatient",,,,"4052","4052",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI QUAN MRI ALYS BRN W/DX MRI","30300201","CDM","610","RC","0866T","HCPCS",,,"facility","outpatient",,,,"4052","4052",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT COLONOGRAPHY W/O DYE","30400001","CDM","352","RC","74261","HCPCS",,,"facility","inpatient",,,,"2682","2682",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT COLONOGRAPHY W/O DYE","30400001","CDM","352","RC","74261","HCPCS",,,"facility","outpatient",,,,"2682","2682",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT PERFUSION ANALYSIS CEREBRAL WITH CONTRAST","30400002","CDM","351","RC","0042T","HCPCS",,,"facility","inpatient",,,,"6626","6626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT PERFUSION ANALYSIS CEREBRAL WITH CONTRAST","30400002","CDM","351","RC","0042T","HCPCS",,,"facility","outpatient",,,,"6626","6626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BRAIN WO CONTR","30400012","CDM","351","RC","70450","HCPCS",,,"facility","inpatient",,,,"4312","4312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BRAIN WO CONTR","30400012","CDM","351","RC","70450","HCPCS",,,"facility","outpatient",,,,"4312","4312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BRAIN W CONTR","30400013","CDM","351","RC","70460","HCPCS",,,"facility","inpatient",,,,"4869","4869",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BRAIN W CONTR","30400013","CDM","351","RC","70460","HCPCS",,,"facility","outpatient",,,,"4869","4869",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BRAIN W AND WO CONTR","30400014","CDM","351","RC","70470","HCPCS",,,"facility","inpatient",,,,"5345","5345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BRAIN W AND WO CONTR","30400014","CDM","351","RC","70470","HCPCS",,,"facility","outpatient",,,,"5345","5345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ORBIT AND SELLA FOSSA WO CONTR","30400015","CDM","351","RC","70480","HCPCS",,,"facility","inpatient",,,,"4511","4511",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ORBIT AND SELLA FOSSA WO CONTR","30400015","CDM","351","RC","70480","HCPCS",,,"facility","outpatient",,,,"4511","4511",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ORBIT AND SELLA FOSSA W CONTR","30400016","CDM","351","RC","70481","HCPCS",,,"facility","inpatient",,,,"5596","5596",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ORBIT AND SELLA FOSSA W CONTR","30400016","CDM","351","RC","70481","HCPCS",,,"facility","outpatient",,,,"5596","5596",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ORBIT AND SELLA FOSSA W AND WO CONTR","30400017","CDM","351","RC","70482","HCPCS",,,"facility","inpatient",,,,"5337","5337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ORBIT AND SELLA FOSSA W AND WO CONTR","30400017","CDM","351","RC","70482","HCPCS",,,"facility","outpatient",,,,"5337","5337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT MAXILLOFACIAL WO CONTR","30400019","CDM","351","RC","70486","HCPCS",,,"facility","inpatient",,,,"4272","4272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT MAXILLOFACIAL WO CONTR","30400019","CDM","351","RC","70486","HCPCS",,,"facility","outpatient",,,,"4272","4272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT MAXILLOFACIAL W CONTR","30400020","CDM","351","RC","70487","HCPCS",,,"facility","inpatient",,,,"5254","5254",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT MAXILLOFACIAL W CONTR","30400020","CDM","351","RC","70487","HCPCS",,,"facility","outpatient",,,,"5254","5254",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT MAXILLOFACIAL W AND WO CONTR","30400021","CDM","351","RC","70488","HCPCS",,,"facility","inpatient",,,,"4353","4353",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT MAXILLOFACIAL W AND WO CONTR","30400021","CDM","351","RC","70488","HCPCS",,,"facility","outpatient",,,,"4353","4353",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT NECK WO CONTR","30400022","CDM","351","RC","70490","HCPCS",,,"facility","inpatient",,,,"4177","4177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT NECK WO CONTR","30400022","CDM","351","RC","70490","HCPCS",,,"facility","outpatient",,,,"4177","4177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT NECK W CONTR","30400023","CDM","351","RC","70491","HCPCS",,,"facility","inpatient",,,,"4995","4995",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT NECK W CONTR","30400023","CDM","351","RC","70491","HCPCS",,,"facility","outpatient",,,,"4995","4995",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT NECK W AND WO CONTR","30400024","CDM","351","RC","70492","HCPCS",,,"facility","inpatient",,,,"4572","4572",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT NECK W AND WO CONTR","30400024","CDM","351","RC","70492","HCPCS",,,"facility","outpatient",,,,"4572","4572",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA HEAD/BRAIN W AND WO CONTR","30400025","CDM","351","RC","70496","HCPCS",,,"facility","inpatient",,,,"6173","6173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA HEAD/BRAIN W AND WO CONTR","30400025","CDM","351","RC","70496","HCPCS",,,"facility","outpatient",,,,"6173","6173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA NECK W AND WO CONTR","30400026","CDM","351","RC","70498","HCPCS",,,"facility","inpatient",,,,"5871","5871",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA NECK W AND WO CONTR","30400026","CDM","351","RC","70498","HCPCS",,,"facility","outpatient",,,,"5871","5871",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT THORAX DX W/O CNTRST","30400027","CDM","352","RC","71250","HCPCS",,,"facility","inpatient",,,,"4097","4097",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT THORAX DX W/O CNTRST","30400027","CDM","352","RC","71250","HCPCS",,,"facility","outpatient",,,,"4097","4097",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT THORAX DX W/CONTRAST","30400029","CDM","352","RC","71260","HCPCS",,,"facility","inpatient",,,,"5153","5153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT THORAX DX W/CONTRAST","30400029","CDM","352","RC","71260","HCPCS",,,"facility","outpatient",,,,"5153","5153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT THORAX DX W/O CNTRST FLWD CNTRST","30400030","CDM","352","RC","71270","HCPCS",,,"facility","inpatient",,,,"5607","5607",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT THORAX DX W/O CNTRST FLWD CNTRST","30400030","CDM","352","RC","71270","HCPCS",,,"facility","outpatient",,,,"5607","5607",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA CHEST W AND WO CONTR","30400031","CDM","350","RC","71275","HCPCS",,,"facility","inpatient",,,,"6885","6885",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA CHEST W AND WO CONTR","30400031","CDM","350","RC","71275","HCPCS",,,"facility","outpatient",,,,"6885","6885",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE CERV WO CONTR","30400032","CDM","352","RC","72125","HCPCS",,,"facility","inpatient",,,,"5058","5058",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE CERV WO CONTR","30400032","CDM","352","RC","72125","HCPCS",,,"facility","outpatient",,,,"5058","5058",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE CERV W CONTR","30400033","CDM","352","RC","72126","HCPCS",,,"facility","inpatient",,,,"7056","7056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE CERV W CONTR","30400033","CDM","352","RC","72126","HCPCS",,,"facility","outpatient",,,,"7056","7056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE CERV W AND WO CONTR","30400034","CDM","352","RC","72127","HCPCS",,,"facility","inpatient",,,,"5699","5699",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE CERV W AND WO CONTR","30400034","CDM","352","RC","72127","HCPCS",,,"facility","outpatient",,,,"5699","5699",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE THOR WO CONTR","30400035","CDM","352","RC","72128","HCPCS",,,"facility","inpatient",,,,"4811","4811",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE THOR WO CONTR","30400035","CDM","352","RC","72128","HCPCS",,,"facility","outpatient",,,,"4811","4811",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE THOR W CONTR","30400036","CDM","352","RC","72129","HCPCS",,,"facility","inpatient",,,,"6600","6600",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE THOR W CONTR","30400036","CDM","352","RC","72129","HCPCS",,,"facility","outpatient",,,,"6600","6600",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE THOR W AND WO CONTR","30400037","CDM","352","RC","72130","HCPCS",,,"facility","inpatient",,,,"6822","6822",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE THOR W AND WO CONTR","30400037","CDM","352","RC","72130","HCPCS",,,"facility","outpatient",,,,"6822","6822",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE LUMB WO CONTR","30400038","CDM","352","RC","72131","HCPCS",,,"facility","inpatient",,,,"4803","4803",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE LUMB WO CONTR","30400038","CDM","352","RC","72131","HCPCS",,,"facility","outpatient",,,,"4803","4803",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE LUMB W CONTR","30400039","CDM","352","RC","72132","HCPCS",,,"facility","inpatient",,,,"6202","6202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE LUMB W CONTR","30400039","CDM","352","RC","72132","HCPCS",,,"facility","outpatient",,,,"6202","6202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE LUMB W AND WO CONTR","30400040","CDM","352","RC","72133","HCPCS",,,"facility","inpatient",,,,"5824","5824",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SPINE LUMB W AND WO CONTR","30400040","CDM","352","RC","72133","HCPCS",,,"facility","outpatient",,,,"5824","5824",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA PELVIS W AND WO CONTR","30400042","CDM","350","RC","72191","HCPCS",,,"facility","inpatient",,,,"5400","5400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA PELVIS W AND WO CONTR","30400042","CDM","350","RC","72191","HCPCS",,,"facility","outpatient",,,,"5400","5400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT PELVIS WO CONTR","30400043","CDM","352","RC","72192","HCPCS",,,"facility","inpatient",,,,"4656","4656",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT PELVIS WO CONTR","30400043","CDM","352","RC","72192","HCPCS",,,"facility","outpatient",,,,"4656","4656",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT PELVIS W CONTR","30400044","CDM","352","RC","72193","HCPCS",,,"facility","inpatient",,,,"5746","5746",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT PELVIS W CONTR","30400044","CDM","352","RC","72193","HCPCS",,,"facility","outpatient",,,,"5746","5746",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT PELVIS W AND WO CONTR","30400045","CDM","352","RC","72194","HCPCS",,,"facility","inpatient",,,,"4196","4196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT PELVIS W AND WO CONTR","30400045","CDM","352","RC","72194","HCPCS",,,"facility","outpatient",,,,"4196","4196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT EXTREM UPPER WO CONTR BIL","30400047","CDM","352","RC","73200","HCPCS",,,"facility","inpatient",,,"50","6398","6398",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM UPPER WO CONTR BIL","30400047","CDM","352","RC","73200","HCPCS",,,"facility","outpatient",,,"50","6398","6398",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM UPPER WO CONTR LT","30400048","CDM","352","RC","73200","HCPCS",,,"facility","inpatient",,,"LT","4265","4265",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM UPPER WO CONTR LT","30400048","CDM","352","RC","73200","HCPCS",,,"facility","outpatient",,,"LT","4265","4265",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM UPPER WO CONTR RT","30400049","CDM","352","RC","73200","HCPCS",,,"facility","inpatient",,,"RT","4265","4265",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM UPPER WO CONTR RT","30400049","CDM","352","RC","73200","HCPCS",,,"facility","outpatient",,,"RT","4265","4265",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM UPPER W CONTR BIL","30400050","CDM","352","RC","73201","HCPCS",,,"facility","inpatient",,,"50","7683","7683",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM UPPER W CONTR BIL","30400050","CDM","352","RC","73201","HCPCS",,,"facility","outpatient",,,"50","7683","7683",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM UPPER W CONTR LT","30400051","CDM","352","RC","73201","HCPCS",,,"facility","inpatient",,,"LT","5122","5122",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM UPPER W CONTR LT","30400051","CDM","352","RC","73201","HCPCS",,,"facility","outpatient",,,"LT","5122","5122",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM UPPER W CONTR RT","30400052","CDM","352","RC","73201","HCPCS",,,"facility","inpatient",,,"RT","5122","5122",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM UPPER W CONTR RT","30400052","CDM","352","RC","73201","HCPCS",,,"facility","outpatient",,,"RT","5122","5122",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM UPPER W AND WO CONTR BIL","30400053","CDM","352","RC","73202","HCPCS",,,"facility","inpatient",,,"50","8422","8422",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM UPPER W AND WO CONTR BIL","30400053","CDM","352","RC","73202","HCPCS",,,"facility","outpatient",,,"50","8422","8422",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM UPPER W AND WO CONTR LT","30400054","CDM","352","RC","73202","HCPCS",,,"facility","inpatient",,,"LT","5615","5615",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM UPPER W AND WO CONTR LT","30400054","CDM","352","RC","73202","HCPCS",,,"facility","outpatient",,,"LT","5615","5615",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM UPPER W AND WO CONTR RT","30400055","CDM","352","RC","73202","HCPCS",,,"facility","inpatient",,,"RT","5615","5615",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM UPPER W AND WO CONTR RT","30400055","CDM","352","RC","73202","HCPCS",,,"facility","outpatient",,,"RT","5615","5615",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CTA EXTREM UPPER W AND WO CONTR LT","30400056","CDM","350","RC","73206","HCPCS",,,"facility","inpatient",,,"LT","5928","5928",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CTA EXTREM UPPER W AND WO CONTR LT","30400056","CDM","350","RC","73206","HCPCS",,,"facility","outpatient",,,"LT","5928","5928",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CTA EXTREM UPPER W AND WO CONTR RT","30400057","CDM","350","RC","73206","HCPCS",,,"facility","inpatient",,,"RT","5928","5928",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CTA EXTREM UPPER W AND WO CONTR RT","30400057","CDM","350","RC","73206","HCPCS",,,"facility","outpatient",,,"RT","5928","5928",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM LOWER WO CONTR BIL","30400058","CDM","352","RC","73700","HCPCS",,,"facility","inpatient",,,"50","6538","6538",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM LOWER WO CONTR BIL","30400058","CDM","352","RC","73700","HCPCS",,,"facility","outpatient",,,"50","6538","6538",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM LOWER WO CONTR LT","30400059","CDM","352","RC","73700","HCPCS",,,"facility","inpatient",,,"LT","4359","4359",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM LOWER WO CONTR LT","30400059","CDM","352","RC","73700","HCPCS",,,"facility","outpatient",,,"LT","4359","4359",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM LOWER WO CONTR RT","30400060","CDM","352","RC","73700","HCPCS",,,"facility","inpatient",,,"RT","4359","4359",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM LOWER WO CONTR RT","30400060","CDM","352","RC","73700","HCPCS",,,"facility","outpatient",,,"RT","4359","4359",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM LOWER W CONTR BIL","30400061","CDM","352","RC","73701","HCPCS",,,"facility","inpatient",,,"50","7974","7974",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM LOWER W CONTR BIL","30400061","CDM","352","RC","73701","HCPCS",,,"facility","outpatient",,,"50","7974","7974",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM LOWER W CONTR LT","30400062","CDM","352","RC","73701","HCPCS",,,"facility","inpatient",,,"LT","5316","5316",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM LOWER W CONTR LT","30400062","CDM","352","RC","73701","HCPCS",,,"facility","outpatient",,,"LT","5316","5316",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM LOWER W CONTR RT","30400063","CDM","352","RC","73701","HCPCS",,,"facility","inpatient",,,"RT","5316","5316",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM LOWER W CONTR RT","30400063","CDM","352","RC","73701","HCPCS",,,"facility","outpatient",,,"RT","5316","5316",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM LOWER W AND WO CONTR BIL","30400064","CDM","352","RC","73702","HCPCS",,,"facility","inpatient",,,"50","8218","8218",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM LOWER W AND WO CONTR BIL","30400064","CDM","352","RC","73702","HCPCS",,,"facility","outpatient",,,"50","8218","8218",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CT EXTREM LOWER W AND WO CONTR LT","30400065","CDM","352","RC","73702","HCPCS",,,"facility","inpatient",,,"LT","5479","5479",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM LOWER W AND WO CONTR LT","30400065","CDM","352","RC","73702","HCPCS",,,"facility","outpatient",,,"LT","5479","5479",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT EXTREM LOWER W AND WO CONTR RT","30400066","CDM","352","RC","73702","HCPCS",,,"facility","inpatient",,,"RT","5479","5479",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT EXTREM LOWER W AND WO CONTR RT","30400066","CDM","352","RC","73702","HCPCS",,,"facility","outpatient",,,"RT","5479","5479",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CTA EXTREM LOWER W AND WO CONTR BIL","30400067","CDM","350","RC","73706","HCPCS",,,"facility","inpatient",,,"50","10260","10260",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CTA EXTREM LOWER W AND WO CONTR BIL","30400067","CDM","350","RC","73706","HCPCS",,,"facility","outpatient",,,"50","10260","10260",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CTA EXTREM LOWER W AND WO CONTR LT","30400068","CDM","350","RC","73706","HCPCS",,,"facility","inpatient",,,"LT","6840","6840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CTA EXTREM LOWER W AND WO CONTR LT","30400068","CDM","350","RC","73706","HCPCS",,,"facility","outpatient",,,"LT","6840","6840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CTA EXTREM LOWER W AND WO CONTR RT","30400069","CDM","350","RC","73706","HCPCS",,,"facility","inpatient",,,"RT","6840","6840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CTA EXTREM LOWER W AND WO CONTR RT","30400069","CDM","350","RC","73706","HCPCS",,,"facility","outpatient",,,"RT","6840","6840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT ABD WO CONTR","30400070","CDM","352","RC","74150","HCPCS",,,"facility","inpatient",,,,"4058","4058",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD WO CONTR","30400070","CDM","352","RC","74150","HCPCS",,,"facility","outpatient",,,,"4058","4058",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD W CONTR","30400071","CDM","352","RC","74160","HCPCS",,,"facility","inpatient",,,,"4755","4755",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD W CONTR","30400071","CDM","352","RC","74160","HCPCS",,,"facility","outpatient",,,,"4755","4755",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD W AND WO CONTR","30400072","CDM","352","RC","74170","HCPCS",,,"facility","inpatient",,,,"4989","4989",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD W AND WO CONTR","30400072","CDM","352","RC","74170","HCPCS",,,"facility","outpatient",,,,"4989","4989",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA ABD W AND WO CONTR","30400073","CDM","350","RC","74175","HCPCS",,,"facility","inpatient",,,,"6496","6496",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA ABD W AND WO CONTR","30400073","CDM","350","RC","74175","HCPCS",,,"facility","outpatient",,,,"6496","6496",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA ABD W RUNOFF W AND WO CONTR","30400074","CDM","350","RC","75635","HCPCS",,,"facility","inpatient",,,,"7047","7047",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA ABD W RUNOFF W AND WO CONTR","30400074","CDM","350","RC","75635","HCPCS",,,"facility","outpatient",,,,"7047","7047",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT 3D RENDERING INTERP & POSTPROCESS SUPERVISION","30400075","CDM","350","RC","76376","HCPCS",,,"facility","inpatient",,,,"1312","1312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT 3D RENDERING INTERP & POSTPROCESS SUPERVISION","30400075","CDM","350","RC","76376","HCPCS",,,"facility","outpatient",,,,"1312","1312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT 3D RENDERING INTERP&POSTPROC DIF WORK STATION","30400076","CDM","350","RC","76377","HCPCS",,,"facility","inpatient",,,,"2034","2034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT 3D RENDERING INTERP&POSTPROC DIF WORK STATION","30400076","CDM","350","RC","76377","HCPCS",,,"facility","outpatient",,,,"2034","2034",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT LTD OR FOLLOW-UP STDY","30400077","CDM","350","RC","76380","HCPCS",,,"facility","inpatient",,,,"1807","1807",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT LTD OR FOLLOW-UP STDY","30400077","CDM","350","RC","76380","HCPCS",,,"facility","outpatient",,,,"1807","1807",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT STEREOTACTIC LOCAL","30400079","CDM","350","RC","77011","HCPCS",,,"facility","inpatient",,,,"14042","14042",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT STEREOTACTIC LOCAL","30400079","CDM","350","RC","77011","HCPCS",,,"facility","outpatient",,,,"14042","14042",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT GUIDE NEEDLE PLACEMENT","30400080","CDM","350","RC","77012","HCPCS",,,"facility","inpatient",,,,"4531","4531",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT GUIDE NEEDLE PLACEMENT","30400080","CDM","350","RC","77012","HCPCS",,,"facility","outpatient",,,,"4531","4531",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT GUIDANCE TISSUE ABLATION","30400081","CDM","350","RC","77013","HCPCS",,,"facility","inpatient",,,,"3962","3962",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT GUIDANCE TISSUE ABLATION","30400081","CDM","350","RC","77013","HCPCS",,,"facility","outpatient",,,,"3962","3962",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT GUIDE RAD THERAPY FIELDS","30400082","CDM","350","RC","77014","HCPCS",,,"facility","inpatient",,,,"2023","2023",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT GUIDE RAD THERAPY FIELDS","30400082","CDM","350","RC","77014","HCPCS",,,"facility","outpatient",,,,"2023","2023",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BONE DENSTY STDY AXIAL","30400084","CDM","350","RC","77078","HCPCS",,,"facility","inpatient",,,,"4470","4470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BONE DENSTY STDY AXIAL","30400084","CDM","350","RC","77078","HCPCS",,,"facility","outpatient",,,,"4470","4470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT COLONOGRAPHY VIRTUAL SCRN","30400088","CDM","352","RC","74263","HCPCS",,,"facility","inpatient",,,,"2491","2491",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT COLONOGRAPHY VIRTUAL SCRN","30400088","CDM","352","RC","74263","HCPCS",,,"facility","outpatient",,,,"2491","2491",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT HRT W/O DYE W/CA TEST","30400091","CDM","352","RC","75571","HCPCS",,,"facility","inpatient",,,,"684","684",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT HRT W/O DYE W/CA TEST","30400091","CDM","352","RC","75571","HCPCS",,,"facility","outpatient",,,,"684","684",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT HRT W/3D IMAGE","30400092","CDM","352","RC","75572","HCPCS",,,"facility","inpatient",,,,"5202","5202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT HRT W/3D IMAGE","30400092","CDM","352","RC","75572","HCPCS",,,"facility","outpatient",,,,"5202","5202",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT HRT C+ STRUX CGEN HRT DS","30400093","CDM","352","RC","75573","HCPCS",,,"facility","inpatient",,,,"10285","10285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT HRT C+ STRUX CGEN HRT DS","30400093","CDM","352","RC","75573","HCPCS",,,"facility","outpatient",,,,"10285","10285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ANGIO HRT W/3D IMAGE","30400094","CDM","352","RC","75574","HCPCS",,,"facility","inpatient",,,,"5054","5054",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ANGIO HRT W/3D IMAGE","30400094","CDM","352","RC","75574","HCPCS",,,"facility","outpatient",,,,"5054","5054",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS ID ABD/PEL RT PER","30400097","CDM","361","RC","49411","HCPCS",,,"facility","inpatient",,,,"6249","6249",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS ID ABD/PEL RT PER","30400097","CDM","361","RC","49411","HCPCS",,,"facility","outpatient",,,,"6249","6249",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIG/BAND ANG AV FIST","30400099","CDM","361","RC","37607","HCPCS",,,"facility","inpatient",,,,"18795","18795",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIG/BAND ANG AV FIST","30400099","CDM","361","RC","37607","HCPCS",,,"facility","outpatient",,,,"18795","18795",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT THORAX LW DOSE LUNG CANCER SCR W/O CONTRAST","30400104","CDM","350","RC","71271","HCPCS",,,"facility","inpatient",,,,"304","304",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT THORAX LW DOSE LUNG CANCER SCR W/O CONTRAST","30400104","CDM","350","RC","71271","HCPCS",,,"facility","outpatient",,,,"304","304",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD & PELVIS W/O CON","30400115","CDM","352","RC","74176","HCPCS",,,"facility","inpatient",,,,"6374","6374",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD & PELVIS W/O CON","30400115","CDM","352","RC","74176","HCPCS",,,"facility","outpatient",,,,"6374","6374",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD & PELVIS W/CON","30400116","CDM","352","RC","74177","HCPCS",,,"facility","inpatient",,,,"8287","8287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD & PELVIS W/CON","30400116","CDM","352","RC","74177","HCPCS",,,"facility","outpatient",,,,"8287","8287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD & PELVIS 1+ REGION W/WO CONTRAST","30400117","CDM","352","RC","74178","HCPCS",,,"facility","inpatient",,,,"8994","8994",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT ABD & PELVIS 1+ REGION W/WO CONTRAST","30400117","CDM","352","RC","74178","HCPCS",,,"facility","outpatient",,,,"8994","8994",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT DRN W CATH PLACE PRC","30400127","CDM","350","RC","75989","HCPCS",,,"facility","inpatient",,,,"3144","3144",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT DRN W CATH PLACE PRC","30400127","CDM","350","RC","75989","HCPCS",,,"facility","outpatient",,,,"3144","3144",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIAGNOSTIC BONE MARROW ASPIRATION","30400133","CDM","361","RC","38220","HCPCS",,,"facility","inpatient",,,,"5120","5120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIAGNOSTIC BONE MARROW ASPIRATION","30400133","CDM","361","RC","38220","HCPCS",,,"facility","outpatient",,,,"5120","5120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT LUNG SCREENING LTD","30400136","CDM","352","RC","71250","HCPCS",,,"facility","inpatient",,,"52","4097","4097",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG CT LUNG SCREENING LTD","30400136","CDM","352","RC","71250","HCPCS",,,"facility","outpatient",,,"52","4097","4097",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG CT BONE LENGTH STUDY","30400138","CDM","350","RC","77073","HCPCS",,,"facility","inpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BONE LENGTH STUDY","30400138","CDM","350","RC","77073","HCPCS",,,"facility","outpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SKELETAL SURVEY WO CONTRAST","30400144","CDM","350","RC","76497","HCPCS",,,"facility","inpatient",,,,"2690","2690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT SKELETAL SURVEY WO CONTRAST","30400144","CDM","350","RC","76497","HCPCS",,,"facility","outpatient",,,,"2690","2690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BREAST W/3D RENDERING UNI W/O CONTRAST LT","30400149","CDM","352","RC","0633T","HCPCS",,,"facility","inpatient",,,"LT","486","486",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT BREAST W/3D RENDERING UNI W/O CONTRAST LT","30400149","CDM","352","RC","0633T","HCPCS",,,"facility","outpatient",,,"LT","486","486",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT BREAST W/3D RENDERING UNI W/O CONTRAST RT","30400150","CDM","352","RC","0633T","HCPCS",,,"facility","inpatient",,,"RT","486","486",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT BREAST W/3D RENDERING UNI W/O CONTRAST RT","30400150","CDM","352","RC","0633T","HCPCS",,,"facility","outpatient",,,"RT","486","486",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT BREAST W/3D RENDERING UNI W/CONTRAST LT","30400151","CDM","352","RC","0634T","HCPCS",,,"facility","inpatient",,,"LT","796","796",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT BREAST W/3D RENDERING UNI W/CONTRAST LT","30400151","CDM","352","RC","0634T","HCPCS",,,"facility","outpatient",,,"LT","796","796",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT BREAST W/3D RENDERING UNI W/CONTRAST RT","30400152","CDM","352","RC","0634T","HCPCS",,,"facility","inpatient",,,"RT","796","796",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT BREAST W/3D RENDERING UNI W/CONTRAST RT","30400152","CDM","352","RC","0634T","HCPCS",,,"facility","outpatient",,,"RT","796","796",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT BRST W/3D RENDERING UNI WO CNTRST FLWD C+ LT","30400153","CDM","352","RC","0635T","HCPCS",,,"facility","inpatient",,,"LT","796","796",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT BRST W/3D RENDERING UNI WO CNTRST FLWD C+ LT","30400153","CDM","352","RC","0635T","HCPCS",,,"facility","outpatient",,,"LT","796","796",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CT BRST W/3D RENDERING UNI WO CNTRST FLWD C+ RT","30400154","CDM","352","RC","0635T","HCPCS",,,"facility","inpatient",,,"RT","796","796",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT BRST W/3D RENDERING UNI WO CNTRST FLWD C+ RT","30400154","CDM","352","RC","0635T","HCPCS",,,"facility","outpatient",,,"RT","796","796",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CT BREAST W/3D RENDERING BI W/O CONTRAST","30400155","CDM","352","RC","0636T","HCPCS",,,"facility","inpatient",,,,"1025","1025",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BREAST W/3D RENDERING BI W/O CONTRAST","30400155","CDM","352","RC","0636T","HCPCS",,,"facility","outpatient",,,,"1025","1025",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BREAST W/3D RENDERING BI W/CONTRAST","30400156","CDM","352","RC","0637T","HCPCS",,,"facility","inpatient",,,,"1636","1636",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BREAST W/3D RENDERING BI W/CONTRAST","30400156","CDM","352","RC","0637T","HCPCS",,,"facility","outpatient",,,,"1636","1636",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BRST W/3D RENDERING BI WO CNTRST FLWD CNTRST","30400157","CDM","352","RC","0638T","HCPCS",,,"facility","inpatient",,,,"1636","1636",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT BRST W/3D RENDERING BI WO CNTRST FLWD CNTRST","30400157","CDM","352","RC","0638T","HCPCS",,,"facility","outpatient",,,,"1636","1636",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT GASTRIC TUBE CHECK W CONTRAST","30400159","CDM","350","RC","76497","HCPCS",,,"facility","inpatient",,,,"1495","1495",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT GASTRIC TUBE CHECK W CONTRAST","30400159","CDM","350","RC","76497","HCPCS",,,"facility","outpatient",,,,"1495","1495",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA HEAD&NECK C+ W/NONCONTRAST IMG&POST-PXESSNG","30400167","CDM","351","RC","70471","HCPCS",,,"facility","inpatient",,,,"12425","12425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA HEAD&NECK C+ W/NONCONTRAST IMG&POST-PXESSNG","30400167","CDM","351","RC","70471","HCPCS",,,"facility","outpatient",,,,"12425","12425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT CERE PRFUJ ALYS C+ W/CT/CTA SAME ANATOMY","30400168","CDM","351","RC","70472","HCPCS",,,"facility","inpatient",,,,"6626","6626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT CERE PRFUJ ALYS C+ W/CT/CTA SAME ANATOMY","30400168","CDM","351","RC","70472","HCPCS",,,"facility","outpatient",,,,"6626","6626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT CERE PRFUJ ALYS C+ W/O CT/CTA SAME ANATOMY","30400169","CDM","351","RC","70473","HCPCS",,,"facility","inpatient",,,,"6626","6626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CT CERE PRFUJ ALYS C+ W/O CT/CTA SAME ANATOMY","30400169","CDM","351","RC","70473","HCPCS",,,"facility","outpatient",,,,"6626","6626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG QUAN&CHARAC C ATHEROSCLERTC PLAQ ASSES SEV C DS","30400170","CDM","350","RC","75577","HCPCS",,,"facility","inpatient",,,,"5974","5974",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG QUAN&CHARAC C ATHEROSCLERTC PLAQ ASSES SEV C DS","30400170","CDM","350","RC","75577","HCPCS",,,"facility","outpatient",,,,"5974","5974",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET MYOCRD IMG METAB EVAL SINGLE STUDY","30500000","CDM","404","RC","78459","HCPCS",,,"facility","inpatient",,,,"6263","6263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET MYOCRD IMG METAB EVAL SINGLE STUDY","30500000","CDM","404","RC","78459","HCPCS",,,"facility","outpatient",,,,"6263","6263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET W/CT ATT SKLL TO THGH","30500001","CDM","404","RC","78815","HCPCS",,,"facility","inpatient",,,,"10792","10792",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET W/CT ATT SKLL TO THGH","30500001","CDM","404","RC","78815","HCPCS",,,"facility","outpatient",,,,"10792","10792",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET TUMOR LIMITED AREA","30500002","CDM","404","RC","78811","HCPCS",,,"facility","inpatient",,,,"8170","8170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET TUMOR LIMITED AREA","30500002","CDM","404","RC","78811","HCPCS",,,"facility","outpatient",,,,"8170","8170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET SKULL TO THIGH","30500003","CDM","404","RC","78812","HCPCS",,,"facility","inpatient",,,,"11271","11271",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET SKULL TO THIGH","30500003","CDM","404","RC","78812","HCPCS",,,"facility","outpatient",,,,"11271","11271",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET TUMOR FULL BODY","30500004","CDM","404","RC","78813","HCPCS",,,"facility","inpatient",,,,"12931","12931",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET TUMOR FULL BODY","30500004","CDM","404","RC","78813","HCPCS",,,"facility","outpatient",,,,"12931","12931",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET W/CT WHOLE BODY","30500005","CDM","404","RC","78816","HCPCS",,,"facility","inpatient",,,,"10739","10739",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET W/CT WHOLE BODY","30500005","CDM","404","RC","78816","HCPCS",,,"facility","outpatient",,,,"10739","10739",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET W/CT ATT ANAT LOC LTD","30500008","CDM","404","RC","78814","HCPCS",,,"facility","inpatient",,,,"9867","9867",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET W/CT ATT ANAT LOC LTD","30500008","CDM","404","RC","78814","HCPCS",,,"facility","outpatient",,,,"9867","9867",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PS BRAIN PERF EVAL","30500010","CDM","404","RC","78609","HCPCS",,,"facility","inpatient",,,"GY","2228","2228",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG PS BRAIN PERF EVAL","30500010","CDM","404","RC","78609","HCPCS",,,"facility","outpatient",,,"GY","2228","2228",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG PET BRAIN METABOLIC INITL","30500011","CDM","404","RC","78608","HCPCS",,,"facility","inpatient",,,"PI","8792","8792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET BRAIN METABOLIC INITL","30500011","CDM","404","RC","78608","HCPCS",,,"facility","outpatient",,,"PI","8792","8792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET BRAIN METABOLIC SUBSQ","30500012","CDM","404","RC","78608","HCPCS",,,"facility","inpatient",,,"PS","8792","8792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET BRAIN METABOLIC SUBSQ","30500012","CDM","404","RC","78608","HCPCS",,,"facility","outpatient",,,"PS","8792","8792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET/CT SKULL-THGH INITL","30500015","CDM","404","RC","78815","HCPCS",,,"facility","inpatient",,,"PI","10792","10792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET/CT SKULL-THGH INITL","30500015","CDM","404","RC","78815","HCPCS",,,"facility","outpatient",,,"PI","10792","10792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET/CT SKULL-THGH SUBSQ","30500016","CDM","404","RC","78815","HCPCS",,,"facility","inpatient",,,"PS","10792","10792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET/CT SKULL-THGH SUBSQ","30500016","CDM","404","RC","78815","HCPCS",,,"facility","outpatient",,,"PS","10792","10792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET/CT WHOLE BODY INITL","30500017","CDM","404","RC","78816","HCPCS",,,"facility","inpatient",,,"PI","10739","10739",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET/CT WHOLE BODY INITL","30500017","CDM","404","RC","78816","HCPCS",,,"facility","outpatient",,,"PI","10739","10739",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET/CT WHOLE BODY SUBSQ","30500018","CDM","404","RC","78816","HCPCS",,,"facility","inpatient",,,"PS","10739","10739",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET/CT WHOLE BODY SUBSQ","30500018","CDM","404","RC","78816","HCPCS",,,"facility","outpatient",,,"PS","10739","10739",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET LIMITED AREA INITL","30500019","CDM","404","RC","78811","HCPCS",,,"facility","inpatient",,,"PI","8170","8170",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET LIMITED AREA INITL","30500019","CDM","404","RC","78811","HCPCS",,,"facility","outpatient",,,"PI","8170","8170",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET SKULL-MID THIGH INITL","30500021","CDM","404","RC","78812","HCPCS",,,"facility","inpatient",,,"PI","11271","11271",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET SKULL-MID THIGH INITL","30500021","CDM","404","RC","78812","HCPCS",,,"facility","outpatient",,,"PI","11271","11271",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET SKULL-MID THIGH SUBSQ","30500022","CDM","404","RC","78812","HCPCS",,,"facility","inpatient",,,"PS","11271","11271",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET SKULL-MID THIGH SUBSQ","30500022","CDM","404","RC","78812","HCPCS",,,"facility","outpatient",,,"PS","11271","11271",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET/CT LTD INITL","30500023","CDM","404","RC","78814","HCPCS",,,"facility","inpatient",,,"PI","9867","9867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET/CT LTD INITL","30500023","CDM","404","RC","78814","HCPCS",,,"facility","outpatient",,,"PI","9867","9867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing"
"HCHG PET/CT LTD SUBSQ","30500024","CDM","404","RC","78814","HCPCS",,,"facility","inpatient",,,"PS","9867","9867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET/CT LTD SUBSQ","30500024","CDM","404","RC","78814","HCPCS",,,"facility","outpatient",,,"PS","9867","9867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy"
"HCHG PET MYOCRD IMG METAB EVAL 1 STUDY CNCRNT W/CT","30500026","CDM","404","RC","78429","HCPCS",,,"facility","inpatient",,,,"6919","6919",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PET MYOCRD IMG METAB EVAL 1 STUDY CNCRNT W/CT","30500026","CDM","404","RC","78429","HCPCS",,,"facility","outpatient",,,,"6919","6919",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID METS WHOLE BODY","30600007","CDM","341","RC","78018","HCPCS",,,"facility","inpatient",,,,"5476","5476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID METS WHOLE BODY","30600007","CDM","341","RC","78018","HCPCS",,,"facility","outpatient",,,,"5476","5476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID METS UPTAKE CALC","30600008","CDM","341","RC","78020","HCPCS",,,"facility","inpatient",,,,"1397","1397",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID METS UPTAKE CALC","30600008","CDM","341","RC","78020","HCPCS",,,"facility","outpatient",,,,"1397","1397",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PARATHYROID PLANAR IMAGING","30600009","CDM","341","RC","78070","HCPCS",,,"facility","inpatient",,,,"2563","2563",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PARATHYROID PLANAR IMAGING","30600009","CDM","341","RC","78070","HCPCS",,,"facility","outpatient",,,,"2563","2563",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE MARROW SINGLE","30600011","CDM","341","RC","78102","HCPCS",,,"facility","inpatient",,,,"2576","2576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE MARROW SINGLE","30600011","CDM","341","RC","78102","HCPCS",,,"facility","outpatient",,,,"2576","2576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE MARROW WHOLE BODY","30600012","CDM","341","RC","78104","HCPCS",,,"facility","inpatient",,,,"4260","4260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE MARROW WHOLE BODY","30600012","CDM","341","RC","78104","HCPCS",,,"facility","outpatient",,,,"4260","4260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PLASMA VOLUME MULTI","30600013","CDM","341","RC","78111","HCPCS",,,"facility","inpatient",,,,"2308","2308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PLASMA VOLUME MULTI","30600013","CDM","341","RC","78111","HCPCS",,,"facility","outpatient",,,,"2308","2308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RED CELL MASS MULTI","30600014","CDM","341","RC","78121","HCPCS",,,"facility","inpatient",,,,"2074","2074",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RED CELL MASS MULTI","30600014","CDM","341","RC","78121","HCPCS",,,"facility","outpatient",,,,"2074","2074",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM WHOLE BLOOD VOLUME","30600015","CDM","341","RC","78122","HCPCS",,,"facility","inpatient",,,,"1903","1903",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM WHOLE BLOOD VOLUME","30600015","CDM","341","RC","78122","HCPCS",,,"facility","outpatient",,,,"1903","1903",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RED CELL SURVIVAL","30600016","CDM","341","RC","78130","HCPCS",,,"facility","inpatient",,,,"4170","4170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RED CELL SURVIVAL","30600016","CDM","341","RC","78130","HCPCS",,,"facility","outpatient",,,,"4170","4170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM SPLEEN SCAN","30600017","CDM","341","RC","78185","HCPCS",,,"facility","inpatient",,,,"4423","4423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM SPLEEN SCAN","30600017","CDM","341","RC","78185","HCPCS",,,"facility","outpatient",,,,"4423","4423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PLATELET SURVIVAL STDY","30600018","CDM","341","RC","78191","HCPCS",,,"facility","inpatient",,,,"2896","2896",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PLATELET SURVIVAL STDY","30600018","CDM","341","RC","78191","HCPCS",,,"facility","outpatient",,,,"2896","2896",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LYMPHATIC PATHWAY WITH IMAGING","30600019","CDM","341","RC","78195","HCPCS",,,"facility","inpatient",,,,"4428","4428",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LYMPHATIC PATHWAY WITH IMAGING","30600019","CDM","341","RC","78195","HCPCS",,,"facility","outpatient",,,,"4428","4428",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LIVER SCAN","30600020","CDM","341","RC","78201","HCPCS",,,"facility","inpatient",,,,"4040","4040",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LIVER SCAN","30600020","CDM","341","RC","78201","HCPCS",,,"facility","outpatient",,,,"4040","4040",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LIVER W VASCULAR FLOW","30600021","CDM","341","RC","78202","HCPCS",,,"facility","inpatient",,,,"4155","4155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LIVER W VASCULAR FLOW","30600021","CDM","341","RC","78202","HCPCS",,,"facility","outpatient",,,,"4155","4155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LIVER SPLEEN SCAN","30600024","CDM","341","RC","78215","HCPCS",,,"facility","inpatient",,,,"3380","3380",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LIVER SPLEEN SCAN","30600024","CDM","341","RC","78215","HCPCS",,,"facility","outpatient",,,,"3380","3380",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LIVER SPLEEN W FLOW","30600025","CDM","341","RC","78216","HCPCS",,,"facility","inpatient",,,,"2209","2209",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LIVER SPLEEN W FLOW","30600025","CDM","341","RC","78216","HCPCS",,,"facility","outpatient",,,,"2209","2209",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM SALIVARY GLAND W SERIAL","30600027","CDM","341","RC","78231","HCPCS",,,"facility","inpatient",,,,"1959","1959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM SALIVARY GLAND W SERIAL","30600027","CDM","341","RC","78231","HCPCS",,,"facility","outpatient",,,,"1959","1959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM ESOPHAGEAL MOTILITY","30600028","CDM","341","RC","78258","HCPCS",,,"facility","inpatient",,,,"1708","1708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM ESOPHAGEAL MOTILITY","30600028","CDM","341","RC","78258","HCPCS",,,"facility","outpatient",,,,"1708","1708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM GASTROESOPHAGEAL REFLUX","30600029","CDM","341","RC","78262","HCPCS",,,"facility","inpatient",,,,"3843","3843",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM GASTROESOPHAGEAL REFLUX","30600029","CDM","341","RC","78262","HCPCS",,,"facility","outpatient",,,,"3843","3843",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM H PYLORI BREATH TEST ACQ","30600031","CDM","300","RC","78267","HCPCS",,,"facility","inpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM H PYLORI BREATH TEST ACQ","30600031","CDM","300","RC","78267","HCPCS",,,"facility","outpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM H PYLORI BREATH TEST ANALYSIS","30600032","CDM","300","RC","78268","HCPCS",,,"facility","inpatient",,,,"2399","2399",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM H PYLORI BREATH TEST ANALYSIS","30600032","CDM","300","RC","78268","HCPCS",,,"facility","outpatient",,,,"2352","2352",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM GI BLEEDING SCAN","30600035","CDM","341","RC","78278","HCPCS",,,"facility","inpatient",,,,"3945","3945",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM GI BLEEDING SCAN","30600035","CDM","341","RC","78278","HCPCS",,,"facility","outpatient",,,,"3945","3945",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BOWEL (MECKELS) SCAN","30600036","CDM","341","RC","78290","HCPCS",,,"facility","inpatient",,,,"4328","4328",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BOWEL (MECKELS) SCAN","30600036","CDM","341","RC","78290","HCPCS",,,"facility","outpatient",,,,"4328","4328",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LEVEEN SHUNT PATENCY","30600037","CDM","341","RC","78291","HCPCS",,,"facility","inpatient",,,,"5141","5141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LEVEEN SHUNT PATENCY","30600037","CDM","341","RC","78291","HCPCS",,,"facility","outpatient",,,,"5141","5141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE SCAN SINGLE AREA","30600038","CDM","341","RC","78300","HCPCS",,,"facility","inpatient",,,,"2432","2432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE SCAN SINGLE AREA","30600038","CDM","341","RC","78300","HCPCS",,,"facility","outpatient",,,,"2432","2432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE SCAN MULTIPLE AREAS","30600039","CDM","341","RC","78305","HCPCS",,,"facility","inpatient",,,,"3347","3347",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE SCAN MULTIPLE AREAS","30600039","CDM","341","RC","78305","HCPCS",,,"facility","outpatient",,,,"3347","3347",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE SCAN WHOLE BODY","30600040","CDM","341","RC","78306","HCPCS",,,"facility","inpatient",,,,"4342","4342",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE SCAN WHOLE BODY","30600040","CDM","341","RC","78306","HCPCS",,,"facility","outpatient",,,,"4342","4342",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE SCAN THREE PHASE","30600041","CDM","341","RC","78315","HCPCS",,,"facility","inpatient",,,,"4874","4874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BONE SCAN THREE PHASE","30600041","CDM","341","RC","78315","HCPCS",,,"facility","outpatient",,,,"4874","4874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CARDIAC (L-R) SHUNT DETECTION","30600043","CDM","341","RC","78428","HCPCS",,,"facility","inpatient",,,,"3516","3516",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CARDIAC (L-R) SHUNT DETECTION","30600043","CDM","341","RC","78428","HCPCS",,,"facility","outpatient",,,,"3516","3516",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM VASCULAR FLOW NONCARDIAC","30600044","CDM","341","RC","78445","HCPCS",,,"facility","inpatient",,,,"3538","3538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM VASCULAR FLOW NONCARDIAC","30600044","CDM","341","RC","78445","HCPCS",,,"facility","outpatient",,,,"3538","3538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM VENOUS THROMBOSIS ACUTE","30600045","CDM","341","RC","78456","HCPCS",,,"facility","inpatient",,,,"6267","6267",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM VENOUS THROMBOSIS ACUTE","30600045","CDM","341","RC","78456","HCPCS",,,"facility","outpatient",,,,"6267","6267",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM VENOG BILATERAL","30600046","CDM","341","RC","78458","HCPCS",,,"facility","inpatient",,,,"4141","4141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM VENOG BILATERAL","30600046","CDM","341","RC","78458","HCPCS",,,"facility","outpatient",,,,"4141","4141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM MYOCARDIAL PERFUSION SINGLE ACQ","30600047","CDM","341","RC","78453","HCPCS",,,"facility","inpatient",,,,"5394","5394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM MYOCARDIAL PERFUSION SINGLE ACQ","30600047","CDM","341","RC","78453","HCPCS",,,"facility","outpatient",,,,"5394","5394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM MYOCARDIAL PERFUSION MULTIPLE ACQ","30600048","CDM","341","RC","78454","HCPCS",,,"facility","inpatient",,,,"7173","7173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM MYOCARDIAL PERFUSION MULTIPLE ACQ","30600048","CDM","341","RC","78454","HCPCS",,,"facility","outpatient",,,,"7173","7173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM MYOCARDIAL PERFUSION SPECT SINGLE ACQ","30600049","CDM","341","RC","78451","HCPCS",,,"facility","inpatient",,,,"7176","7176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM MYOCARDIAL PERFUSION SPECT SINGLE ACQ","30600049","CDM","341","RC","78451","HCPCS",,,"facility","outpatient",,,,"7176","7176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM MYOCARDIAL PERFUSION SPECT MULTI ACQ","30600050","CDM","341","RC","78452","HCPCS",,,"facility","inpatient",,,,"9698","9698",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM MYOCARDIAL PERFUSION SPECT MULTI ACQ","30600050","CDM","341","RC","78452","HCPCS",,,"facility","outpatient",,,,"9698","9698",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART MYOCARDIAL INFARCTION SCAN","30600051","CDM","341","RC","78466","HCPCS",,,"facility","inpatient",,,,"3319","3319",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART MYOCARDIAL INFARCTION SCAN","30600051","CDM","341","RC","78466","HCPCS",,,"facility","outpatient",,,,"3319","3319",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART MYOCARDIAL INFARCTION SCAN W SPECT","30600053","CDM","341","RC","78469","HCPCS",,,"facility","inpatient",,,,"4795","4795",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART MYOCARDIAL INFARCTION SCAN W SPECT","30600053","CDM","341","RC","78469","HCPCS",,,"facility","outpatient",,,,"4795","4795",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART GATED WALL MOTION (MUGA) SINGLE ACQ","30600054","CDM","341","RC","78472","HCPCS",,,"facility","inpatient",,,,"3159","3159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART GATED WALL MOTION (MUGA) SINGLE ACQ","30600054","CDM","341","RC","78472","HCPCS",,,"facility","outpatient",,,,"3159","3159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART GATED WALL MOTION (MUGA) MULTIPLE ACQ","30600055","CDM","341","RC","78473","HCPCS",,,"facility","inpatient",,,,"3674","3674",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART GATED WALL MOTION (MUGA) MULTIPLE ACQ","30600055","CDM","341","RC","78473","HCPCS",,,"facility","outpatient",,,,"3674","3674",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART GATED WALL MOTION (MUGA) SPECT","30600059","CDM","341","RC","78494","HCPCS",,,"facility","inpatient",,,,"3537","3537",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEART GATED WALL MOTION (MUGA) SPECT","30600059","CDM","341","RC","78494","HCPCS",,,"facility","outpatient",,,,"3537","3537",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG PERFUSION IMAGING","30600061","CDM","341","RC","78580","HCPCS",,,"facility","inpatient",,,,"3215","3215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG PERFUSION IMAGING","30600061","CDM","341","RC","78580","HCPCS",,,"facility","outpatient",,,,"3215","3215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BRAIN SCAN LTD W FLOW","30600068","CDM","341","RC","78601","HCPCS",,,"facility","inpatient",,,,"3561","3561",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BRAIN SCAN LTD W FLOW","30600068","CDM","341","RC","78601","HCPCS",,,"facility","outpatient",,,,"3561","3561",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BRAIN SCAN COMPLETE","30600069","CDM","341","RC","78605","HCPCS",,,"facility","inpatient",,,,"3704","3704",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BRAIN SCAN COMPLETE","30600069","CDM","341","RC","78605","HCPCS",,,"facility","outpatient",,,,"3704","3704",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BRAIN SCAN COMPLETE W FLOW","30600070","CDM","341","RC","78606","HCPCS",,,"facility","inpatient",,,,"6332","6332",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BRAIN SCAN COMPLETE W FLOW","30600070","CDM","341","RC","78606","HCPCS",,,"facility","outpatient",,,,"6332","6332",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CISTERNOG","30600073","CDM","341","RC","78630","HCPCS",,,"facility","inpatient",,,,"2044","2044",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CISTERNOG","30600073","CDM","341","RC","78630","HCPCS",,,"facility","outpatient",,,,"2044","2044",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CSF SHUNT EVAL","30600074","CDM","341","RC","78645","HCPCS",,,"facility","inpatient",,,,"2102","2102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CSF SHUNT EVAL","30600074","CDM","341","RC","78645","HCPCS",,,"facility","outpatient",,,,"2102","2102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CSF LEAKAGE DETECT","30600076","CDM","341","RC","78650","HCPCS",,,"facility","inpatient",,,,"5626","5626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CSF LEAKAGE DETECT","30600076","CDM","341","RC","78650","HCPCS",,,"facility","outpatient",,,,"5626","5626",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENAL SINGLE ACQ","30600077","CDM","341","RC","78700","HCPCS",,,"facility","inpatient",,,,"3635","3635",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENAL SINGLE ACQ","30600077","CDM","341","RC","78700","HCPCS",,,"facility","outpatient",,,,"3635","3635",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENAL W FLOW","30600078","CDM","341","RC","78701","HCPCS",,,"facility","inpatient",,,,"3153","3153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENAL W FLOW","30600078","CDM","341","RC","78701","HCPCS",,,"facility","outpatient",,,,"3153","3153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENOG SINGLE ACQ WO PHARM","30600079","CDM","341","RC","78707","HCPCS",,,"facility","inpatient",,,,"4147","4147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENOG SINGLE ACQ WO PHARM","30600079","CDM","341","RC","78707","HCPCS",,,"facility","outpatient",,,,"4147","4147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENOG SINGLE ACQ W PHARM","30600080","CDM","341","RC","78708","HCPCS",,,"facility","inpatient",,,,"4467","4467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENOG SINGLE ACQ W PHARM","30600080","CDM","341","RC","78708","HCPCS",,,"facility","outpatient",,,,"4467","4467",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENOG MULTIPLE ACQ W AND WO PHARM","30600081","CDM","341","RC","78709","HCPCS",,,"facility","inpatient",,,,"6538","6538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENOG MULTIPLE ACQ W AND WO PHARM","30600081","CDM","341","RC","78709","HCPCS",,,"facility","outpatient",,,,"6538","6538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENAL FUNCTION NO SCAN (GFR)","30600083","CDM","341","RC","78725","HCPCS",,,"facility","inpatient",,,,"1719","1719",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RENAL FUNCTION NO SCAN (GFR)","30600083","CDM","341","RC","78725","HCPCS",,,"facility","outpatient",,,,"1719","1719",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CYSTOG W VOIDING","30600084","CDM","341","RC","78740","HCPCS",,,"facility","inpatient",,,,"3349","3349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM CYSTOG W VOIDING","30600084","CDM","341","RC","78740","HCPCS",,,"facility","outpatient",,,,"3349","3349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM TESTICULAR W FLOW","30600085","CDM","341","RC","78761","HCPCS",,,"facility","inpatient",,,,"2156","2156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM TESTICULAR W FLOW","30600085","CDM","341","RC","78761","HCPCS",,,"facility","outpatient",,,,"2156","2156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZJ TUM PLNR 1 AREA SINGLE DAY IMAGING","30600086","CDM","341","RC","78800","HCPCS",,,"facility","inpatient",,,,"2555","2555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZJ TUM PLNR 1 AREA SINGLE DAY IMAGING","30600086","CDM","341","RC","78800","HCPCS",,,"facility","outpatient",,,,"2555","2555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCTUM PLNR 2+AREA 1+D IMG/1 AREA IMG>2+D","30600087","CDM","341","RC","78801","HCPCS",,,"facility","inpatient",,,,"2716","2716",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCTUM PLNR 2+AREA 1+D IMG/1 AREA IMG>2+D","30600087","CDM","341","RC","78801","HCPCS",,,"facility","outpatient",,,,"2716","2716",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCTUM PLNR WHOLE BODY SINGLE DAY IMAGING","30600088","CDM","341","RC","78802","HCPCS",,,"facility","inpatient",,,,"6051","6051",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCTUM PLNR WHOLE BODY SINGLE DAY IMAGING","30600088","CDM","341","RC","78802","HCPCS",,,"facility","outpatient",,,,"6051","6051",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZJ TUM SPECT 1 AREA SINGLE DAY IMAGIN","30600089","CDM","341","RC","78803","HCPCS",,,"facility","inpatient",,,,"5048","5048",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZJ TUM SPECT 1 AREA SINGLE DAY IMAGIN","30600089","CDM","341","RC","78803","HCPCS",,,"facility","outpatient",,,,"5048","5048",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZJ TUM PLNR WHOLE BODY 2+ DAYS IMAGIN","30600090","CDM","341","RC","78804","HCPCS",,,"facility","inpatient",,,,"5601","5601",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZJ TUM PLNR WHOLE BODY 2+ DAYS IMAGIN","30600090","CDM","341","RC","78804","HCPCS",,,"facility","outpatient",,,,"5601","5601",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THERAPY ORAL ADMIN","30600097","CDM","342","RC","79005","HCPCS",,,"facility","inpatient",,,,"2289","2289",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THERAPY ORAL ADMIN","30600097","CDM","342","RC","79005","HCPCS",,,"facility","outpatient",,,,"2289","2289",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THERAPY IV ADMIN","30600098","CDM","342","RC","79101","HCPCS",,,"facility","inpatient",,,,"1822","1822",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THERAPY IV ADMIN","30600098","CDM","342","RC","79101","HCPCS",,,"facility","outpatient",,,,"1822","1822",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THERAPY INTRACAVITARY ADMIN","30600099","CDM","342","RC","79200","HCPCS",,,"facility","inpatient",,,,"2010","2010",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THERAPY INTRACAVITARY ADMIN","30600099","CDM","342","RC","79200","HCPCS",,,"facility","outpatient",,,,"2010","2010",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THERAPY MONOCLONAL AB IV INFUSION","30600100","CDM","342","RC","79403","HCPCS",,,"facility","inpatient",,,,"2710","2710",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THERAPY MONOCLONAL AB IV INFUSION","30600100","CDM","342","RC","79403","HCPCS",,,"facility","outpatient",,,,"2710","2710",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SPECIAL MEDICAL RADIATION PHYSICS CONSULT","30600102","CDM","333","RC","77370","HCPCS",,,"facility","inpatient",,,,"2476","2476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SPECIAL MEDICAL RADIATION PHYSICS CONSULT","30600102","CDM","333","RC","77370","HCPCS",,,"facility","outpatient",,,,"2476","2476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BRAIN FLOW ONLY","30600132","CDM","341","RC","78610","HCPCS",,,"facility","inpatient",,,,"3603","3603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM BRAIN FLOW ONLY","30600132","CDM","341","RC","78610","HCPCS",,,"facility","outpatient",,,,"3603","3603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEPATOBILIRY SYS IMAGE","30600140","CDM","341","RC","78226","HCPCS",,,"facility","inpatient",,,,"3581","3581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEPATOBILIRY SYS IMAGE","30600140","CDM","341","RC","78226","HCPCS",,,"facility","outpatient",,,,"3581","3581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEPATO SYS IMAG W/DRUG","30600141","CDM","341","RC","78227","HCPCS",,,"facility","inpatient",,,,"4107","4107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM HEPATO SYS IMAG W/DRUG","30600141","CDM","341","RC","78227","HCPCS",,,"facility","outpatient",,,,"4107","4107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG VENTILATION IMAGE","30600142","CDM","341","RC","78579","HCPCS",,,"facility","inpatient",,,,"2310","2310",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG VENTILATION IMAGE","30600142","CDM","341","RC","78579","HCPCS",,,"facility","outpatient",,,,"2310","2310",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG VENT&PERFUS IMAGE","30600143","CDM","341","RC","78582","HCPCS",,,"facility","inpatient",,,,"4562","4562",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG VENT&PERFUS IMAGE","30600143","CDM","341","RC","78582","HCPCS",,,"facility","outpatient",,,,"4562","4562",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG PERFUSION DIFFERL","30600144","CDM","341","RC","78597","HCPCS",,,"facility","inpatient",,,,"2153","2153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG PERFUSION DIFFERL","30600144","CDM","341","RC","78597","HCPCS",,,"facility","outpatient",,,,"2153","2153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG PERF&VENT DIFFERL","30600145","CDM","341","RC","78598","HCPCS",,,"facility","inpatient",,,,"4083","4083",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM LUNG PERF&VENT DIFFERL","30600145","CDM","341","RC","78598","HCPCS",,,"facility","outpatient",,,,"4083","4083",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID UPTAKE MEASUREMENT","30600158","CDM","341","RC","78012","HCPCS",,,"facility","inpatient",,,,"1895","1895",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID UPTAKE MEASUREMENT","30600158","CDM","341","RC","78012","HCPCS",,,"facility","outpatient",,,,"1895","1895",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID IMAGING W/BLOOD FLOW","30600159","CDM","341","RC","78013","HCPCS",,,"facility","inpatient",,,,"175","175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID IMAGING W/BLOOD FLOW","30600159","CDM","341","RC","78013","HCPCS",,,"facility","outpatient",,,,"175","175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID IMAGING W/BLD FLOW UPTAKE MEASURE","30600160","CDM","341","RC","78014","HCPCS",,,"facility","inpatient",,,,"2319","2319",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM THYROID IMAGING W/BLD FLOW UPTAKE MEASURE","30600160","CDM","341","RC","78014","HCPCS",,,"facility","outpatient",,,,"2319","2319",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PARATHYROID PLANAR W/TOMOGRAPHIC (SPECT)","30600161","CDM","341","RC","78071","HCPCS",,,"facility","inpatient",,,,"4163","4163",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PARATHYROID PLANAR W/TOMOGRAPHIC (SPECT)","30600161","CDM","341","RC","78071","HCPCS",,,"facility","outpatient",,,,"4163","4163",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PARATHYROID PLANAR W/SPECT & CT","30600162","CDM","341","RC","78072","HCPCS",,,"facility","inpatient",,,,"3509","3509",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM PARATHYROID PLANAR W/SPECT & CT","30600162","CDM","341","RC","78072","HCPCS",,,"facility","outpatient",,,,"3509","3509",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTRIC EMPTYING IMAGING STUDY","30600166","CDM","341","RC","78264","HCPCS",,,"facility","inpatient",,,,"4274","4274",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTRIC EMPTYING IMAGING STUDY","30600166","CDM","341","RC","78264","HCPCS",,,"facility","outpatient",,,,"4274","4274",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMG","30600169","CDM","341","RC","78830","HCPCS",,,"facility","inpatient",,,,"6242","6242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMG","30600169","CDM","341","RC","78830","HCPCS",,,"facility","outpatient",,,,"6242","6242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZ TUM SPECT 2AREA 1D IMG/1 AR IMG>2+D","30600170","CDM","341","RC","78831","HCPCS",,,"facility","inpatient",,,,"3885","3885",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCLZ TUM SPECT 2AREA 1D IMG/1 AR IMG>2+D","30600170","CDM","341","RC","78831","HCPCS",,,"facility","outpatient",,,,"3885","3885",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCL TUM SPECT CT 2AR 1D IMG/1 AR IMG>2+D","30600171","CDM","341","RC","78832","HCPCS",,,"facility","inpatient",,,,"8841","8841",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP LOCL TUM SPECT CT 2AR 1D IMG/1 AR IMG>2+D","30600171","CDM","341","RC","78832","HCPCS",,,"facility","outpatient",,,,"8841","8841",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP QUANTIFICATION MEAS SINGLE AREA","30600172","CDM","341","RC","78835","HCPCS",,,"facility","inpatient",,,,"1395","1395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RP QUANTIFICATION MEAS SINGLE AREA","30600172","CDM","341","RC","78835","HCPCS",,,"facility","outpatient",,,,"1395","1395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SIMULATION SIMPLE","30700005","CDM","333","RC","77280","HCPCS",,,"facility","inpatient",,,,"2924","2924",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SIMULATION SIMPLE","30700005","CDM","333","RC","77280","HCPCS",,,"facility","outpatient",,,,"2924","2924",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SIMULATION INTERMEDIATE","30700006","CDM","333","RC","77285","HCPCS",,,"facility","inpatient",,,,"3154","3154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SIMULATION INTERMEDIATE","30700006","CDM","333","RC","77285","HCPCS",,,"facility","outpatient",,,,"3154","3154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SIMULATION COMPLEX","30700007","CDM","333","RC","77290","HCPCS",,,"facility","inpatient",,,,"5584","5584",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SIMULATION COMPLEX","30700007","CDM","333","RC","77290","HCPCS",,,"facility","outpatient",,,,"5584","5584",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO 3D PLAN","30700008","CDM","333","RC","77295","HCPCS",,,"facility","inpatient",,,,"12764","12764",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO 3D PLAN","30700008","CDM","333","RC","77295","HCPCS",,,"facility","outpatient",,,,"12764","12764",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO BASIC DOSIMETRY CALCULATION","30700009","CDM","333","RC","77300","HCPCS",,,"facility","inpatient",,,,"1523","1523",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO BASIC DOSIMETRY CALCULATION","30700009","CDM","333","RC","77300","HCPCS",,,"facility","outpatient",,,,"1523","1523",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO IMRT PLANNING","30700010","CDM","333","RC","77301","HCPCS",,,"facility","inpatient",,,,"16949","16949",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO IMRT PLANNING","30700010","CDM","333","RC","77301","HCPCS",,,"facility","outpatient",,,,"16949","16949",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SPECIAL TELETHERAPY PORT PLAN","30700014","CDM","333","RC","77321","HCPCS",,,"facility","inpatient",,,,"3099","3099",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SPECIAL TELETHERAPY PORT PLAN","30700014","CDM","333","RC","77321","HCPCS",,,"facility","outpatient",,,,"3099","3099",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SPECIAL DOSIMETRY","30700018","CDM","333","RC","77331","HCPCS",,,"facility","inpatient",,,,"1417","1417",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SPECIAL DOSIMETRY","30700018","CDM","333","RC","77331","HCPCS",,,"facility","outpatient",,,,"1417","1417",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO TREATMENT DEVICE SIMPLE","30700019","CDM","333","RC","77332","HCPCS",,,"facility","inpatient",,,,"1297","1297",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO TREATMENT DEVICE SIMPLE","30700019","CDM","333","RC","77332","HCPCS",,,"facility","outpatient",,,,"1297","1297",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO TREATMENT DEVICE INTERMEDIATE","30700020","CDM","333","RC","77333","HCPCS",,,"facility","inpatient",,,,"1648","1648",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO TREATMENT DEVICE INTERMEDIATE","30700020","CDM","333","RC","77333","HCPCS",,,"facility","outpatient",,,,"1648","1648",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO TREATMENT DEVICE COMPLEX","30700021","CDM","333","RC","77334","HCPCS",,,"facility","inpatient",,,,"2951","2951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO TREATMENT DEVICE COMPLEX","30700021","CDM","333","RC","77334","HCPCS",,,"facility","outpatient",,,,"2951","2951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO RESPIRATOR MOTION MGMT SIMUL","30700023","CDM","333","RC","77293","HCPCS",,,"facility","inpatient",,,,"2480","2480",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO RESPIRATOR MOTION MGMT SIMUL","30700023","CDM","333","RC","77293","HCPCS",,,"facility","outpatient",,,,"2480","2480",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TELETHX ISODOSE PLAN SIMPLE","30700024","CDM","333","RC","77306","HCPCS",,,"facility","inpatient",,,,"2099","2099",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TELETHX ISODOSE PLAN SIMPLE","30700024","CDM","333","RC","77306","HCPCS",,,"facility","outpatient",,,,"2099","2099",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO CONTINUING MEDICAL PHYSICS CONSULT WKLY","30700025","CDM","333","RC","77336","HCPCS",,,"facility","inpatient",,,,"1828","1828",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO CONTINUING MEDICAL PHYSICS CONSULT WKLY","30700025","CDM","333","RC","77336","HCPCS",,,"facility","outpatient",,,,"1828","1828",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TELETHX ISODOSE PLAN CPLX","30700026","CDM","333","RC","77307","HCPCS",,,"facility","inpatient",,,,"5643","5643",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TELETHX ISODOSE PLAN CPLX","30700026","CDM","333","RC","77307","HCPCS",,,"facility","outpatient",,,,"5643","5643",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO RADIATION TX DELIVERY LVL 1","30700031","CDM","333","RC","77402","HCPCS",,,"facility","inpatient",,,,"1637","1637",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO RADIATION TX DELIVERY LVL 1","30700031","CDM","333","RC","77402","HCPCS",,,"facility","outpatient",,,,"1637","1637",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO RADIATION TX DELIVERY LVL 2","30700035","CDM","333","RC","77407","HCPCS",,,"facility","inpatient",,,,"6187","6187",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO RADIATION TX DELIVERY LVL 2","30700035","CDM","333","RC","77407","HCPCS",,,"facility","outpatient",,,,"6187","6187",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO RADIATION TX DELIVERY LVL 3","30700039","CDM","333","RC","77412","HCPCS",,,"facility","inpatient",,,,"8864","8864",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO RADIATION TX DELIVERY LVL 3","30700039","CDM","333","RC","77412","HCPCS",,,"facility","outpatient",,,,"8864","8864",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO PORT IMAGE(S)","30700043","CDM","333","RC","77417","HCPCS",,,"facility","inpatient",,,,"949","949",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO PORT IMAGE(S)","30700043","CDM","333","RC","77417","HCPCS",,,"facility","outpatient",,,,"949","949",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SPECIAL TREATMENT PROCEDURE","30700046","CDM","333","RC","77470","HCPCS",,,"facility","inpatient",,,,"5046","5046",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SPECIAL TREATMENT PROCEDURE","30700046","CDM","333","RC","77470","HCPCS",,,"facility","outpatient",,,,"5046","5046",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO INTRSTITL RAD SRC APP CMPLX INC SUP HNDL LOAD","30700054","CDM","333","RC","77778","HCPCS",,,"facility","inpatient",,,,"8023","8023",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO INTRSTITL RAD SRC APP CMPLX INC SUP HNDL LOAD","30700054","CDM","333","RC","77778","HCPCS",,,"facility","outpatient",,,,"8023","8023",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SOURCE HANDLING AND LOADING","30700060","CDM","342","RC","77790","HCPCS",,,"facility","inpatient",,,,"513","513",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO SOURCE HANDLING AND LOADING","30700060","CDM","342","RC","77790","HCPCS",,,"facility","outpatient",,,,"513","513",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO LINEAR ACCELERATOR BASED FRACTIONATED SRS MAX 5","30700061","CDM","333","RC","77373","HCPCS",,,"facility","inpatient",,,,"14886","14886",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO LINEAR ACCELERATOR BASED FRACTIONATED SRS MAX 5","30700061","CDM","333","RC","77373","HCPCS",,,"facility","outpatient",,,,"14886","14886",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO LINEAR ACCELERATOR BASED SRS","30700062","CDM","333","RC","77372","HCPCS",,,"facility","inpatient",,,,"40789","40789",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO LINEAR ACCELERATOR BASED SRS","30700062","CDM","333","RC","77372","HCPCS",,,"facility","outpatient",,,,"40789","40789",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RO INTRA-ART RPHARM RX","30700076","CDM","342","RC","79445","HCPCS",,,"facility","inpatient",,,,"2193","2193",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NM RO INTRA-ART RPHARM RX","30700076","CDM","342","RC","79445","HCPCS",,,"facility","outpatient",,,,"2193","2193",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO DSIGN MLC DEV FOR IMRT","30700083","CDM","333","RC","77338","HCPCS",,,"facility","inpatient",,,,"4708","4708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO DSIGN MLC DEV FOR IMRT","30700083","CDM","333","RC","77338","HCPCS",,,"facility","outpatient",,,,"4708","4708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO REF BREAST APPL PLACE/REMV","30700099","CDM","333","RC","C9726","HCPCS",,,"facility","inpatient",,,,"28929","28929",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO REF BREAST APPL PLACE/REMV","30700099","CDM","333","RC","C9726","HCPCS",,,"facility","outpatient",,,,"28929","28929",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO IO RAD TX DELIVERY BY X-RAY","30700100","CDM","333","RC","77424","HCPCS",,,"facility","inpatient",,,,"3433","3433",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO IO RAD TX DELIVERY BY X-RAY","30700100","CDM","333","RC","77424","HCPCS",,,"facility","outpatient",,,,"3433","3433",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE BREAST CATH RAD","30700106","CDM","361","RC","19297","HCPCS",,,"facility","inpatient",,,,"4261","4261",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLACE BREAST CATH RAD","30700106","CDM","361","RC","19297","HCPCS",,,"facility","outpatient",,,,"4261","4261",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS VAG BRACHYTX DEVCE","30700109","CDM","361","RC","57156","HCPCS",,,"facility","inpatient",,,,"2976","2976",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS VAG BRACHYTX DEVCE","30700109","CDM","361","RC","57156","HCPCS",,,"facility","outpatient",,,,"2976","2976",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRACHYTX ISODOSE PLAN SIMPLE","30700113","CDM","333","RC","77316","HCPCS",,,"facility","inpatient",,,,"2178","2178",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRACHYTX ISODOSE PLAN SIMPLE","30700113","CDM","333","RC","77316","HCPCS",,,"facility","outpatient",,,,"2178","2178",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRACHYTX ISODOSE INTERMED","30700114","CDM","333","RC","77317","HCPCS",,,"facility","inpatient",,,,"3253","3253",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRACHYTX ISODOSE INTERMED","30700114","CDM","333","RC","77317","HCPCS",,,"facility","outpatient",,,,"3253","3253",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRACHYTX ISODOSE COMPLEX","30700115","CDM","333","RC","77318","HCPCS",,,"facility","inpatient",,,,"7059","7059",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRACHYTX ISODOSE COMPLEX","30700115","CDM","333","RC","77318","HCPCS",,,"facility","outpatient",,,,"7059","7059",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NTSTY MODUL RAD TX DLVR SMPL","30700116","CDM","333","RC","77385","HCPCS",,,"facility","inpatient",,,,"6646","6646",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NTSTY MODUL RAD TX DLVR SMPL","30700116","CDM","333","RC","77385","HCPCS",,,"facility","outpatient",,,,"6646","6646",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NTSTY MODUL RAD TX DLVR CPLX","30700117","CDM","333","RC","77386","HCPCS",,,"facility","inpatient",,,,"7955","7955",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NTSTY MODUL RAD TX DLVR CPLX","30700117","CDM","333","RC","77386","HCPCS",,,"facility","outpatient",,,,"7955","7955",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GUIDANCE FOR RADIATION TX","30700118","CDM","333","RC","77387","HCPCS",,,"facility","inpatient",,,,"1493","1493",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GUIDANCE FOR RADIATION TX","30700118","CDM","333","RC","77387","HCPCS",,,"facility","outpatient",,,,"1493","1493",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO HDR RDNCL NTRSTL/ICAV BRCHTX 1 CHANNEL","30700122","CDM","333","RC","77770","HCPCS",,,"facility","inpatient",,,,"8538","8538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO HDR RDNCL NTRSTL/ICAV BRCHTX 1 CHANNEL","30700122","CDM","333","RC","77770","HCPCS",,,"facility","outpatient",,,,"8538","8538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO HDR RDNCL NTRSTL/ICAV BRCHTX 2-12 CHANNELS","30700123","CDM","333","RC","77771","HCPCS",,,"facility","inpatient",,,,"10188","10188",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO HDR RDNCL NTRSTL/ICAV BRCHTX 2-12 CHANNELS","30700123","CDM","333","RC","77771","HCPCS",,,"facility","outpatient",,,,"10188","10188",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO HDR RDNCL NTRSTL/ICAV BRCHTX >12 CHANNELS","30700124","CDM","333","RC","77772","HCPCS",,,"facility","inpatient",,,,"19089","19089",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RO HDR RDNCL NTRSTL/ICAV BRCHTX >12 CHANNELS","30700124","CDM","333","RC","77772","HCPCS",,,"facility","outpatient",,,,"19089","19089",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORNRY THROMB W/ASPIRATION OR EXTRAC CATHETER","30900003","CDM","480","RC","93799","HCPCS",,,"facility","inpatient",,,,"9294","9294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORNRY THROMB W/ASPIRATION OR EXTRAC CATHETER","30900003","CDM","480","RC","93799","HCPCS",,,"facility","outpatient",,,,"9294","9294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML C ANGIOPLASTY 1 MAJ C ART&/BRANCHES","30900005","CDM","480","RC","92920","HCPCS",,,"facility","inpatient",,,,"28817","28817",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML C ANGIOPLASTY 1 MAJ C ART&/BRANCHES","30900005","CDM","480","RC","92920","HCPCS",,,"facility","outpatient",,,,"28817","28817",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ CARDIAC ANGIO ADDL ART","30900006","CDM","481","RC","92921","HCPCS",,,"facility","inpatient",,,,"24337","24337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ CARDIAC ANGIO ADDL ART","30900006","CDM","481","RC","92921","HCPCS",,,"facility","outpatient",,,,"24337","24337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML C ATHRC ANGIOP 1 MAJ C ART&/BRNCH","30900007","CDM","480","RC","92924","HCPCS",,,"facility","inpatient",,,,"53609","53609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML C ATHRC ANGIOP 1 MAJ C ART&/BRNCH","30900007","CDM","480","RC","92924","HCPCS",,,"facility","outpatient",,,,"53609","53609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ CARD ANGIO/ATHRECT ADDL","30900008","CDM","481","RC","92925","HCPCS",,,"facility","inpatient",,,,"4367","4367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ CARD ANGIO/ATHRECT ADDL","30900008","CDM","481","RC","92925","HCPCS",,,"facility","outpatient",,,,"4367","4367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TCAT PLMT NTRAC ST 1 LES 1+C SEGMENTS","30900009","CDM","480","RC","92928","HCPCS",,,"facility","inpatient",,,,"47101","47101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TCAT PLMT NTRAC ST 1 LES 1+C SEGMENTS","30900009","CDM","480","RC","92928","HCPCS",,,"facility","outpatient",,,,"47101","47101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ CARD STENT W/ANGIO ADDL","30900010","CDM","481","RC","92929","HCPCS",,,"facility","inpatient",,,,"38229","38229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ CARD STENT W/ANGIO ADDL","30900010","CDM","481","RC","92929","HCPCS",,,"facility","outpatient",,,,"38229","38229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUM C ATHRC ST ANGIOP 1 MAJ C ART&/BRNCH","30900011","CDM","480","RC","92933","HCPCS",,,"facility","inpatient",,,,"57972","57972",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUM C ATHRC ST ANGIOP 1 MAJ C ART&/BRNCH","30900011","CDM","480","RC","92933","HCPCS",,,"facility","outpatient",,,,"57972","57972",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUM REVSC OF/-CAB GRF 1 MAJ C ART&/BRNCH","30900013","CDM","480","RC","92937","HCPCS",,,"facility","inpatient",,,,"44625","44625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUM REVSC OF/-CAB GRF 1 MAJ C ART&/BRNCH","30900013","CDM","480","RC","92937","HCPCS",,,"facility","outpatient",,,,"44625","44625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML REVSC TOT/STOT OCCLS AMI 1MAJ C ART","30900015","CDM","480","RC","92941","HCPCS",,,"facility","inpatient",,,,"45308","45308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML REVSC TOT/STOT OCCLS AMI 1MAJ C ART","30900015","CDM","480","RC","92941","HCPCS",,,"facility","outpatient",,,,"45308","45308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML REVSC CHRNC TOT OCCL 1 C ART ANTGRD","30900016","CDM","480","RC","92943","HCPCS",,,"facility","inpatient",,,,"48953","48953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML REVSC CHRNC TOT OCCL 1 C ART ANTGRD","30900016","CDM","480","RC","92943","HCPCS",,,"facility","outpatient",,,,"48953","48953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMPRE EP EVAL TX SVT","30900018","CDM","481","RC","93653","HCPCS",,,"facility","inpatient",,,,"78332","78332",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMPRE EP EVAL TX SVT","30900018","CDM","481","RC","93653","HCPCS",,,"facility","outpatient",,,,"78332","78332",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMPRE EP EVAL TX VT","30900019","CDM","481","RC","93654","HCPCS",,,"facility","inpatient",,,,"84918","84918",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMPRE EP EVAL TX VT","30900019","CDM","481","RC","93654","HCPCS",,,"facility","outpatient",,,,"84918","84918",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ABLATE ARRHYTHMIA ADD ON","30900020","CDM","481","RC","93655","HCPCS",,,"facility","inpatient",,,,"29463","29463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ABLATE ARRHYTHMIA ADD ON","30900020","CDM","481","RC","93655","HCPCS",,,"facility","outpatient",,,,"29463","29463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMPRE EP EVAL ABLTJ ATR FIB","30900021","CDM","481","RC","93656","HCPCS",,,"facility","inpatient",,,,"90645","90645",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMPRE EP EVAL ABLTJ ATR FIB","30900021","CDM","481","RC","93656","HCPCS",,,"facility","outpatient",,,,"90645","90645",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TX L/R ATRIAL FIB ADDL","30900022","CDM","481","RC","93657","HCPCS",,,"facility","inpatient",,,,"31029","31029",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TX L/R ATRIAL FIB ADDL","30900022","CDM","481","RC","93657","HCPCS",,,"facility","outpatient",,,,"31029","31029",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE OPEN AXILARY ARTERY","30900024","CDM","361","RC","33363","HCPCS",,,"facility","inpatient",,,,"15361","15361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE OPEN AXILARY ARTERY","30900024","CDM","361","RC","33363","HCPCS",,,"facility","outpatient",,,,"15361","15361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE OPEN FEMORAL ARTERY","30900025","CDM","361","RC","33362","HCPCS",,,"facility","inpatient",,,,"78268","78268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE OPEN FEMORAL ARTERY","30900025","CDM","361","RC","33362","HCPCS",,,"facility","outpatient",,,,"78268","78268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE PERQ FEMORAL ARTERY","30900026","CDM","361","RC","33361","HCPCS",,,"facility","inpatient",,,,"58880","58880",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE PERQ FEMORAL ARTERY","30900026","CDM","361","RC","33361","HCPCS",,,"facility","outpatient",,,,"58880","58880",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL PERQ L HRT VAD ARTL/ARTL&VEN SEP INSJ","30900027","CDM","361","RC","33992","HCPCS",,,"facility","inpatient",,,,"2349","2349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL PERQ L HRT VAD ARTL/ARTL&VEN SEP INSJ","30900027","CDM","361","RC","33992","HCPCS",,,"facility","outpatient",,,,"2349","2349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT VAD LEFT ARTERY ACCESS","30900029","CDM","361","RC","33990","HCPCS",,,"facility","inpatient",,,,"30404","30404",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT VAD LEFT ARTERY ACCESS","30900029","CDM","361","RC","33990","HCPCS",,,"facility","outpatient",,,,"30404","30404",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MECH REMVL PERICATH OBST MATERIAL CV DVC","30900036","CDM","320","RC","75901","HCPCS",,,"facility","inpatient",,,,"1479","1479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MECH REMVL PERICATH OBST MATERIAL CV DVC","30900036","CDM","320","RC","75901","HCPCS",,,"facility","outpatient",,,,"1479","1479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CV CATH MECH CLEAR","30900037","CDM","320","RC","75902","HCPCS",,,"facility","inpatient",,,,"997","997",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CV CATH MECH CLEAR","30900037","CDM","320","RC","75902","HCPCS",,,"facility","outpatient",,,,"997","997",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPOSITIONING PERQ R/L VAD W/IMG GDN SEP INSJ","30900043","CDM","361","RC","33993","HCPCS",,,"facility","inpatient",,,,"8249","8249",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPOSITIONING PERQ R/L VAD W/IMG GDN SEP INSJ","30900043","CDM","361","RC","33993","HCPCS",,,"facility","outpatient",,,,"8249","8249",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH CLOSURE PDA","30900044","CDM","481","RC","93582","HCPCS",,,"facility","inpatient",,,,"16373","16373",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH CLOSURE PDA","30900044","CDM","481","RC","93582","HCPCS",,,"facility","outpatient",,,,"16373","16373",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH SEPTAL REDUXN","30900045","CDM","481","RC","93583","HCPCS",,,"facility","inpatient",,,,"44114","44114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH SEPTAL REDUXN","30900045","CDM","481","RC","93583","HCPCS",,,"facility","outpatient",,,,"44114","44114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRCATH REPLACE AORTIC VALVE","30900046","CDM","361","RC","33366","HCPCS",,,"facility","inpatient",,,,"81672","81672",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRCATH REPLACE AORTIC VALVE","30900046","CDM","361","RC","33366","HCPCS",,,"facility","outpatient",,,,"81672","81672",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE OPEN TRANSAORTIC APPROACH","30900047","CDM","361","RC","33365","HCPCS",,,"facility","inpatient",,,,"18225","18225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE OPEN TRANSAORTIC APPROACH","30900047","CDM","361","RC","33365","HCPCS",,,"facility","outpatient",,,,"18225","18225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE W/BYPASS PERC PA VENOUS CANN","30900048","CDM","361","RC","33367","HCPCS",,,"facility","inpatient",,,,"6302","6302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE AORTIC VALVE W/BYPASS PERC PA VENOUS CANN","30900048","CDM","361","RC","33367","HCPCS",,,"facility","outpatient",,,,"6302","6302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CINE/VIDEO","30900058","CDM","320","RC","76120","HCPCS",,,"facility","inpatient",,,,"2498","2498",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XR CINE/VIDEO","30900058","CDM","320","RC","76120","HCPCS",,,"facility","outpatient",,,,"2498","2498",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ BAL VALVULOPLASTY AORTIC","30900064","CDM","481","RC","92986","HCPCS",,,"facility","inpatient",,,,"28864","28864",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ BAL VALVULOPLASTY AORTIC","30900064","CDM","481","RC","92986","HCPCS",,,"facility","outpatient",,,,"28864","28864",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INSERT/PLACE FLOW DIRECTED CATH FOR MONITOR","30900069","CDM","481","RC","93503","HCPCS",,,"facility","inpatient",,,,"6433","6433",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INSERT/PLACE FLOW DIRECTED CATH FOR MONITOR","30900069","CDM","481","RC","93503","HCPCS",,,"facility","outpatient",,,,"6433","6433",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA BIOPSY ENDOMYOCARDIAL","30900070","CDM","481","RC","93505","HCPCS",,,"facility","inpatient",,,,"9444","9444",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA BIOPSY ENDOMYOCARDIAL","30900070","CDM","481","RC","93505","HCPCS",,,"facility","outpatient",,,,"9444","9444",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA HEART CATH RIGHT CONGENITAL ANOMALIES","30900078","CDM","481","RC","93530","HCPCS",,,"facility","outpatient",,,,"12584","12584",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA HEART CATH RT/LT RETRO CONG CARDIAC ANOMOLIES","30900079","CDM","481","RC","93531","HCPCS",,,"facility","outpatient",,,,"31732","31732",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA IV DOPPLER VELCTY/PRSSRE CORO ANGIO INIT VSL","30900091","CDM","481","RC","93571","HCPCS",,,"facility","inpatient",,,,"6737","6737",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA IV DOPPLER VELCTY/PRSSRE CORO ANGIO INIT VSL","30900091","CDM","481","RC","93571","HCPCS",,,"facility","outpatient",,,,"6737","6737",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRAVASCULAR DOPPLER W STRESS ADD VESS","30900092","CDM","481","RC","93572","HCPCS",,,"facility","inpatient",,,,"3372","3372",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRAVASCULAR DOPPLER W STRESS ADD VESS","30900092","CDM","481","RC","93572","HCPCS",,,"facility","outpatient",,,,"3372","3372",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ASD OR PFO CLOSURE WITH IMPLANT","30900093","CDM","481","RC","93580","HCPCS",,,"facility","inpatient",,,,"51223","51223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ASD OR PFO CLOSURE WITH IMPLANT","30900093","CDM","481","RC","93580","HCPCS",,,"facility","outpatient",,,,"51223","51223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONGENTIAL VSD CLOSURE","30900094","CDM","481","RC","93581","HCPCS",,,"facility","inpatient",,,,"50901","50901",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONGENTIAL VSD CLOSURE","30900094","CDM","481","RC","93581","HCPCS",,,"facility","outpatient",,,,"50901","50901",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEART CATH WITH ILIAC ANGIOGRAPHY","30900097","CDM","481","RC","G0278","HCPCS",,,"facility","inpatient",,,,"5635","5635",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEART CATH WITH ILIAC ANGIOGRAPHY","30900097","CDM","481","RC","G0278","HCPCS",,,"facility","outpatient",,,,"5635","5635",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML CORONARY MCHNL ASPIR THROMBECTOMY","30900101","CDM","480","RC","92973","HCPCS",,,"facility","inpatient",,,,"19401","19401",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRLUML CORONARY MCHNL ASPIR THROMBECTOMY","30900101","CDM","480","RC","92973","HCPCS",,,"facility","outpatient",,,,"19401","19401",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORONARY THROMBOLYSIS INTRAVENOUS INFUSION","30900103","CDM","480","RC","92977","HCPCS",,,"facility","inpatient",,,,"2484","2484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORONARY THROMBOLYSIS INTRAVENOUS INFUSION","30900103","CDM","480","RC","92977","HCPCS",,,"facility","outpatient",,,,"2484","2484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ENDOLUMINL IVUS OCT C 1ST","30900104","CDM","480","RC","92978","HCPCS",,,"facility","inpatient",,,,"14262","14262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ENDOLUMINL IVUS OCT C 1ST","30900104","CDM","480","RC","92978","HCPCS",,,"facility","outpatient",,,,"14262","14262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CA ENDOLUMINL IVUS OCT C EA","30900105","CDM","480","RC","92979","HCPCS",,,"facility","inpatient",,,,"9888","9888",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CA ENDOLUMINL IVUS OCT C EA","30900105","CDM","480","RC","92979","HCPCS",,,"facility","outpatient",,,,"9888","9888",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ BAL VALVULOPLASTY MITRAL","30900108","CDM","480","RC","92987","HCPCS",,,"facility","inpatient",,,,"19501","19501",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ BAL VALVULOPLASTY MITRAL","30900108","CDM","480","RC","92987","HCPCS",,,"facility","outpatient",,,,"19501","19501",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PB VALVULOPLASTY PULMON VALVE","30900109","CDM","480","RC","92990","HCPCS",,,"facility","inpatient",,,,"12582","12582",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PB VALVULOPLASTY PULMON VALVE","30900109","CDM","480","RC","92990","HCPCS",,,"facility","outpatient",,,,"12582","12582",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA HEART CATH R AND L CONGENITAL ANOMALIES THR","30900112","CDM","481","RC","93533","HCPCS",,,"facility","outpatient",,,,"36565","36565",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA BUNDLE OF HIS RECORDING","30900113","CDM","480","RC","93600","HCPCS",,,"facility","inpatient",,,,"10506","10506",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA BUNDLE OF HIS RECORDING","30900113","CDM","480","RC","93600","HCPCS",,,"facility","outpatient",,,,"10506","10506",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRA ARTERIAL RECORDING","30900114","CDM","480","RC","93602","HCPCS",,,"facility","inpatient",,,,"2874","2874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRA ARTERIAL RECORDING","30900114","CDM","480","RC","93602","HCPCS",,,"facility","outpatient",,,,"2874","2874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA RIGHT VENTRICULAR RECORDING","30900115","CDM","480","RC","93603","HCPCS",,,"facility","inpatient",,,,"3154","3154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA RIGHT VENTRICULAR RECORDING","30900115","CDM","480","RC","93603","HCPCS",,,"facility","outpatient",,,,"3154","3154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRAVENT/ART MAP TACHY SITE ID ORIG OF TACHY","30900116","CDM","480","RC","93609","HCPCS",,,"facility","inpatient",,,,"15090","15090",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRAVENT/ART MAP TACHY SITE ID ORIG OF TACHY","30900116","CDM","480","RC","93609","HCPCS",,,"facility","outpatient",,,,"15090","15090",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRAVENTRICULAR PACING","30900118","CDM","480","RC","93612","HCPCS",,,"facility","inpatient",,,,"4301","4301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRAVENTRICULAR PACING","30900118","CDM","480","RC","93612","HCPCS",,,"facility","outpatient",,,,"4301","4301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRACARDIAC EP 3 DIMENSIONAL MAPPING","30900119","CDM","480","RC","93613","HCPCS",,,"facility","inpatient",,,,"17806","17806",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRACARDIAC EP 3 DIMENSIONAL MAPPING","30900119","CDM","480","RC","93613","HCPCS",,,"facility","outpatient",,,,"17806","17806",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ESOPHAGEAL RECORDING ATRIAL ELECTROGRAM","30900120","CDM","480","RC","93615","HCPCS",,,"facility","inpatient",,,,"744","744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ESOPHAGEAL RECORDING ATRIAL ELECTROGRAM","30900120","CDM","480","RC","93615","HCPCS",,,"facility","outpatient",,,,"744","744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INDUCTION ARRHYTHMIA BY ELECTRICAL PACING","30900122","CDM","480","RC","93618","HCPCS",,,"facility","inpatient",,,,"7585","7585",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INDUCTION ARRHYTHMIA BY ELECTRICAL PACING","30900122","CDM","480","RC","93618","HCPCS",,,"facility","outpatient",,,,"7585","7585",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMP EP EVAL W RT A/V PCNG/HIS RCRD WO INDUCT","30900123","CDM","480","RC","93619","HCPCS",,,"facility","inpatient",,,,"26865","26865",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMP EP EVAL W RT A/V PCNG/HIS RCRD WO INDUCT","30900123","CDM","480","RC","93619","HCPCS",,,"facility","outpatient",,,,"26865","26865",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMP EP EVAL W RT A/V PCNG/HIS RCRD W INDUCTN","30900124","CDM","480","RC","93620","HCPCS",,,"facility","inpatient",,,,"29957","29957",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMP EP EVAL W RT A/V PCNG/HIS RCRD W INDUCTN","30900124","CDM","480","RC","93620","HCPCS",,,"facility","outpatient",,,,"29957","29957",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMP EP EVAL W LEFT ATRIAL PCNG/RECORD","30900125","CDM","480","RC","93621","HCPCS",,,"facility","inpatient",,,,"15797","15797",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMP EP EVAL W LEFT ATRIAL PCNG/RECORD","30900125","CDM","480","RC","93621","HCPCS",,,"facility","outpatient",,,,"15797","15797",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMP EP EVAL W LEFT VENT PCNG/RECORD","30900126","CDM","480","RC","93622","HCPCS",,,"facility","inpatient",,,,"13438","13438",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA COMP EP EVAL W LEFT VENT PCNG/RECORD","30900126","CDM","480","RC","93622","HCPCS",,,"facility","outpatient",,,,"13438","13438",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PROGRAMMED STIM/PACING AFTER IV DRUG INFUSION","30900127","CDM","480","RC","93623","HCPCS",,,"facility","inpatient",,,,"13343","13343",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PROGRAMMED STIM/PACING AFTER IV DRUG INFUSION","30900127","CDM","480","RC","93623","HCPCS",,,"facility","outpatient",,,,"13343","13343",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EP FOLLOW UP STDY W PCNG/RECORD W INDCTN","30900128","CDM","480","RC","93624","HCPCS",,,"facility","inpatient",,,,"7600","7600",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EP FOLLOW UP STDY W PCNG/RECORD W INDCTN","30900128","CDM","480","RC","93624","HCPCS",,,"facility","outpatient",,,,"7600","7600",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EP EVAL ICD LEADS INITIAL IMPLANT/REPLACE","30900129","CDM","480","RC","93640","HCPCS",,,"facility","inpatient",,,,"4452","4452",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EP EVAL ICD LEADS INITIAL IMPLANT/REPLACE","30900129","CDM","480","RC","93640","HCPCS",,,"facility","outpatient",,,,"4452","4452",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EP EVAL ICD LEADS/GEN INITIAL IMPLANT/REPLACE","30900130","CDM","480","RC","93641","HCPCS",,,"facility","inpatient",,,,"7078","7078",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EP EVAL ICD LEADS/GEN INITIAL IMPLANT/REPLACE","30900130","CDM","480","RC","93641","HCPCS",,,"facility","outpatient",,,,"7078","7078",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EP EVAL SINGLE/DUAL TRNSVNS PAC CARD DEFIB","30900131","CDM","480","RC","93642","HCPCS",,,"facility","inpatient",,,,"5803","5803",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EP EVAL SINGLE/DUAL TRNSVNS PAC CARD DEFIB","30900131","CDM","480","RC","93642","HCPCS",,,"facility","outpatient",,,,"5803","5803",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRACARD CATH ABLATION AV NODE FX/CONDUCTION","30900132","CDM","480","RC","93650","HCPCS",,,"facility","inpatient",,,,"31879","31879",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRACARD CATH ABLATION AV NODE FX/CONDUCTION","30900132","CDM","480","RC","93650","HCPCS",,,"facility","outpatient",,,,"31879","31879",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R&L HRT CA W/VENTRCL","30900136","CDM","481","RC","93453","HCPCS",,,"facility","inpatient",,,,"37116","37116",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R&L HRT CA W/VENTRCL","30900136","CDM","481","RC","93453","HCPCS",,,"facility","outpatient",,,,"37116","37116",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORNRY ARTRY ANGIO S&I","30900137","CDM","481","RC","93454","HCPCS",,,"facility","inpatient",,,,"27999","27999",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORNRY ARTRY ANGIO S&I","30900137","CDM","481","RC","93454","HCPCS",,,"facility","outpatient",,,,"27999","27999",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORNRY ART/GRFT ANGIO","30900138","CDM","481","RC","93455","HCPCS",,,"facility","inpatient",,,,"29893","29893",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORNRY ART/GRFT ANGIO","30900138","CDM","481","RC","93455","HCPCS",,,"facility","outpatient",,,,"29893","29893",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORONRY ART ANGIO RHC","30900139","CDM","481","RC","93456","HCPCS",,,"facility","inpatient",,,,"43888","43888",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORONRY ART ANGIO RHC","30900139","CDM","481","RC","93456","HCPCS",,,"facility","outpatient",,,,"43888","43888",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R HRT ART/GRFT ANGIO","30900140","CDM","481","RC","93457","HCPCS",,,"facility","inpatient",,,,"46213","46213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R HRT ART/GRFT ANGIO","30900140","CDM","481","RC","93457","HCPCS",,,"facility","outpatient",,,,"46213","46213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORONRY ART ANGIO LHC","30900141","CDM","481","RC","93458","HCPCS",,,"facility","inpatient",,,,"39399","39399",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CORONRY ART ANGIO LHC","30900141","CDM","481","RC","93458","HCPCS",,,"facility","outpatient",,,,"39399","39399",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA L HRT ART/GRFT ANGIO","30900142","CDM","481","RC","93459","HCPCS",,,"facility","inpatient",,,,"46421","46421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA L HRT ART/GRFT ANGIO","30900142","CDM","481","RC","93459","HCPCS",,,"facility","outpatient",,,,"46421","46421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R&L ART/VENTRCL ANGIO","30900143","CDM","481","RC","93460","HCPCS",,,"facility","inpatient",,,,"47393","47393",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R&L ART/VENTRCL ANGIO","30900143","CDM","481","RC","93460","HCPCS",,,"facility","outpatient",,,,"47393","47393",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R&L ART/VENT ANGIO BYP","30900144","CDM","481","RC","93461","HCPCS",,,"facility","inpatient",,,,"45969","45969",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R&L ART/VENT ANGIO BYP","30900144","CDM","481","RC","93461","HCPCS",,,"facility","outpatient",,,,"45969","45969",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA LFT CATH TRNSPTL PUNCT","30900145","CDM","481","RC","93462","HCPCS",,,"facility","inpatient",,,,"20861","20861",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA LFT CATH TRNSPTL PUNCT","30900145","CDM","481","RC","93462","HCPCS",,,"facility","outpatient",,,,"20861","20861",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJ CONGENTL CARD CATH","30900146","CDM","481","RC","93563","HCPCS",,,"facility","inpatient",,,,"2991","2991",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJ CONGENTL CARD CATH","30900146","CDM","481","RC","93563","HCPCS",,,"facility","outpatient",,,,"2991","2991",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJ R VENTR/ARTL ANGIO","30900148","CDM","481","RC","93566","HCPCS",,,"facility","inpatient",,,,"2977","2977",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJ R VENTR/ARTL ANGIO","30900148","CDM","481","RC","93566","HCPCS",,,"facility","outpatient",,,,"2977","2977",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJ SUPRVLV AORTOGRPHY","30900149","CDM","481","RC","93567","HCPCS",,,"facility","inpatient",,,,"5479","5479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJ SUPRVLV AORTOGRPHY","30900149","CDM","481","RC","93567","HCPCS",,,"facility","outpatient",,,,"5479","5479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJECT PULM HRT CATH","30900150","CDM","481","RC","93568","HCPCS",,,"facility","inpatient",,,,"4373","4373",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJECT PULM HRT CATH","30900150","CDM","481","RC","93568","HCPCS",,,"facility","outpatient",,,,"4373","4373",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA DRG ADM & HEMODYN MEAS","30900151","CDM","481","RC","93463","HCPCS",,,"facility","inpatient",,,,"4105","4105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA DRG ADM & HEMODYN MEAS","30900151","CDM","481","RC","93463","HCPCS",,,"facility","outpatient",,,,"4105","4105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA LT HRT CATH W/VENTGRHY","30900152","CDM","481","RC","93452","HCPCS",,,"facility","inpatient",,,,"28551","28551",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA LT HRT CATH W/VENTGRHY","30900152","CDM","481","RC","93452","HCPCS",,,"facility","outpatient",,,,"28551","28551",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA RIGHT HEART CATH","30900153","CDM","481","RC","93451","HCPCS",,,"facility","inpatient",,,,"18918","18918",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA RIGHT HEART CATH","30900153","CDM","481","RC","93451","HCPCS",,,"facility","outpatient",,,,"18918","18918",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REM IAB ASIST DEV PRC","30900154","CDM","361","RC","33968","HCPCS",,,"facility","inpatient",,,,"141","141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REM IAB ASIST DEV PRC","30900154","CDM","361","RC","33968","HCPCS",,,"facility","outpatient",,,,"141","141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CARDIOASSIST INTERNAL","30900157","CDM","480","RC","92970","HCPCS",,,"facility","inpatient",,,,"2664","2664",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CARDIOASSIST INTERNAL","30900157","CDM","480","RC","92970","HCPCS",,,"facility","outpatient",,,,"2664","2664",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TILT TABLE TEST","30900159","CDM","480","RC","93660","HCPCS",,,"facility","inpatient",,,,"4199","4199",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TILT TABLE TEST","30900159","CDM","480","RC","93660","HCPCS",,,"facility","outpatient",,,,"4199","4199",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PCR 1L INTG DV EV W RP","30900161","CDM","480","RC","93288","HCPCS",,,"facility","inpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PCR 1L INTG DV EV W RP","30900161","CDM","480","RC","93288","HCPCS",,,"facility","outpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PC 1L INTG DV EV WO RP","30900164","CDM","480","RC","93288","HCPCS",,,"facility","inpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PC 1L INTG DV EV WO RP","30900164","CDM","480","RC","93288","HCPCS",,,"facility","outpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PULSE GEN MULT LEADS","30900165","CDM","361","RC","33221","HCPCS",,,"facility","inpatient",,,,"28861","28861",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PULSE GEN MULT LEADS","30900165","CDM","361","RC","33221","HCPCS",,,"facility","outpatient",,,,"28861","28861",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE&REPLACE PM GEN SINGL","30900166","CDM","361","RC","33227","HCPCS",,,"facility","inpatient",,,,"31611","31611",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE&REPLACE PM GEN SINGL","30900166","CDM","361","RC","33227","HCPCS",,,"facility","outpatient",,,,"31611","31611",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMV&REPLC PM GEN DUAL LEAD","30900167","CDM","361","RC","33228","HCPCS",,,"facility","inpatient",,,,"33697","33697",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMV&REPLC PM GEN DUAL LEAD","30900167","CDM","361","RC","33228","HCPCS",,,"facility","outpatient",,,,"33697","33697",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMV&REPLC PM GEN MULT LEADS","30900168","CDM","361","RC","33229","HCPCS",,,"facility","inpatient",,,,"45589","45589",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMV&REPLC PM GEN MULT LEADS","30900168","CDM","361","RC","33229","HCPCS",,,"facility","outpatient",,,,"45589","45589",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT IMP DEFIB PULSE GEN ONLY W 2 LEADS","30900169","CDM","361","RC","33230","HCPCS",,,"facility","inpatient",,,,"12654","12654",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT IMP DEFIB PULSE GEN ONLY W 2 LEADS","30900169","CDM","361","RC","33230","HCPCS",,,"facility","outpatient",,,,"12654","12654",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT IMP DEFIB PULSE GEN ONLY W MULTI LEADS","30900170","CDM","361","RC","33231","HCPCS",,,"facility","inpatient",,,,"115900","115900",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT IMP DEFIB PULSE GEN ONLY W MULTI LEADS","30900170","CDM","361","RC","33231","HCPCS",,,"facility","outpatient",,,,"115900","115900",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE REPLACE IMP DEFIB PULS GEN SYS 1 LEAD","30900171","CDM","361","RC","33262","HCPCS",,,"facility","inpatient",,,,"80378","80378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE REPLACE IMP DEFIB PULS GEN SYS 1 LEAD","30900171","CDM","361","RC","33262","HCPCS",,,"facility","outpatient",,,,"80378","80378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE REPLACE IMP DEFIB PULS GEN SYS DUAL LEAD","30900172","CDM","361","RC","33263","HCPCS",,,"facility","inpatient",,,,"78628","78628",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE REPLACE IMP DEFIB PULS GEN SYS DUAL LEAD","30900172","CDM","361","RC","33263","HCPCS",,,"facility","outpatient",,,,"78628","78628",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE REPLACE IMP DEFIB PULS GEN SYS MULT LEAD","30900173","CDM","361","RC","33264","HCPCS",,,"facility","inpatient",,,,"86622","86622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE REPLACE IMP DEFIB PULS GEN SYS MULT LEAD","30900173","CDM","361","RC","33264","HCPCS",,,"facility","outpatient",,,,"86622","86622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PLACE RAD DEL DEVICE","30900174","CDM","480","RC","92974","HCPCS",,,"facility","inpatient",,,,"10219","10219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PLACE RAD DEL DEVICE","30900174","CDM","480","RC","92974","HCPCS",,,"facility","outpatient",,,,"10219","10219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TTE W-W/O FL W/CON COM","30900175","CDM","483","RC","C8921","HCPCS",,,"facility","inpatient",,,,"2559","2559",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TTE W-W/O FL W/CON COM","30900175","CDM","483","RC","C8921","HCPCS",,,"facility","outpatient",,,,"2559","2559",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJ L VENTR/ARTL ANGIO","30900180","CDM","481","RC","93565","HCPCS",,,"facility","inpatient",,,,"2926","2926",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INJ L VENTR/ARTL ANGIO","30900180","CDM","481","RC","93565","HCPCS",,,"facility","outpatient",,,,"2926","2926",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EXERCISE STUDY W/MEASR","30900187","CDM","481","RC","93464","HCPCS",,,"facility","inpatient",,,,"505","505",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA EXERCISE STUDY W/MEASR","30900187","CDM","481","RC","93464","HCPCS",,,"facility","outpatient",,,,"505","505",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERIOP IMP DEFIB DEVICE EVAL","30900192","CDM","480","RC","93287","HCPCS",,,"facility","inpatient",,,,"448","448",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERIOP IMP DEFIB DEVICE EVAL","30900192","CDM","480","RC","93287","HCPCS",,,"facility","outpatient",,,,"448","448",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC DRUG-EL COR STENT SING","30900193","CDM","481","RC","C9600","HCPCS",,,"facility","inpatient",,,,"46398","46398",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC DRUG-EL COR STENT SING","30900193","CDM","481","RC","C9600","HCPCS",,,"facility","outpatient",,,,"46398","46398",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC DRUG-EL COR STENT BRAN","30900194","CDM","481","RC","C9601","HCPCS",,,"facility","inpatient",,,,"33886","33886",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC DRUG-EL COR STENT BRAN","30900194","CDM","481","RC","C9601","HCPCS",,,"facility","outpatient",,,,"33886","33886",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR STENT ATHER S","30900195","CDM","481","RC","C9602","HCPCS",,,"facility","inpatient",,,,"53998","53998",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR STENT ATHER S","30900195","CDM","481","RC","C9602","HCPCS",,,"facility","outpatient",,,,"53998","53998",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR STENT ATHER BR","30900196","CDM","481","RC","C9603","HCPCS",,,"facility","inpatient",,,,"41471","41471",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR STENT ATHER BR","30900196","CDM","481","RC","C9603","HCPCS",,,"facility","outpatient",,,,"41471","41471",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC T CABG S","30900197","CDM","481","RC","C9604","HCPCS",,,"facility","inpatient",,,,"42981","42981",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC T CABG S","30900197","CDM","481","RC","C9604","HCPCS",,,"facility","outpatient",,,,"42981","42981",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC T CABG B","30900198","CDM","481","RC","C9605","HCPCS",,,"facility","inpatient",,,,"30577","30577",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC T CABG B","30900198","CDM","481","RC","C9605","HCPCS",,,"facility","outpatient",,,,"30577","30577",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC W AMI S","30900199","CDM","481","RC","C9606","HCPCS",,,"facility","inpatient",,,,"45050","45050",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC W AMI S","30900199","CDM","481","RC","C9606","HCPCS",,,"facility","outpatient",,,,"45050","45050",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC CHRO SIN","30900200","CDM","481","RC","C9607","HCPCS",,,"facility","inpatient",,,,"49767","49767",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC CHRO SIN","30900200","CDM","481","RC","C9607","HCPCS",,,"facility","outpatient",,,,"49767","49767",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC CHRO ADD","30900201","CDM","481","RC","C9608","HCPCS",,,"facility","inpatient",,,,"38451","38451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERC D-E COR REVASC CHRO ADD","30900201","CDM","481","RC","C9608","HCPCS",,,"facility","outpatient",,,,"38451","38451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS/REP SUBQ DEFIBRILLATOR","30900205","CDM","361","RC","33270","HCPCS",,,"facility","inpatient",,,,"106893","106893",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INS/REP SUBQ DEFIBRILLATOR","30900205","CDM","361","RC","33270","HCPCS",,,"facility","outpatient",,,,"106893","106893",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT SUBQ IMPLANTABLE DEFIB ELECTRODE","30900206","CDM","361","RC","33271","HCPCS",,,"facility","inpatient",,,,"28302","28302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT SUBQ IMPLANTABLE DEFIB ELECTRODE","30900206","CDM","361","RC","33271","HCPCS",,,"facility","outpatient",,,,"28302","28302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMVL SUBQ IMPLTBL DFB ELCTRD","30900207","CDM","361","RC","33272","HCPCS",,,"facility","inpatient",,,,"7244","7244",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMVL SUBQ IMPLTBL DFB ELCTRD","30900207","CDM","361","RC","33272","HCPCS",,,"facility","outpatient",,,,"7244","7244",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR TCAT MITRAL VALVE IINITIAL PROSTH","30900212","CDM","361","RC","33418","HCPCS",,,"facility","inpatient",,,,"53468","53468",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR TCAT MITRAL VALVE IINITIAL PROSTH","30900212","CDM","361","RC","33418","HCPCS",,,"facility","outpatient",,,,"53468","53468",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR TCAT MITRAL VALVEA ADDL PROSTH","30900213","CDM","361","RC","33419","HCPCS",,,"facility","inpatient",,,,"28049","28049",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPAIR TCAT MITRAL VALVEA ADDL PROSTH","30900213","CDM","361","RC","33419","HCPCS",,,"facility","outpatient",,,,"28049","28049",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IFR CA IV DPPLR VELCTY/PRSSRE INIT VSL LIMITED","30900219","CDM","481","RC","93571","HCPCS",,,"facility","inpatient",,,,"5115","5115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IFR CA IV DPPLR VELCTY/PRSSRE INIT VSL LIMITED","30900219","CDM","481","RC","93571","HCPCS",,,"facility","outpatient",,,,"5115","5115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IFR CA IV DPPLR VELCTY/PRSSRE  ADDL VSLS LIMITED","30900220","CDM","481","RC","93572","HCPCS",,,"facility","inpatient",,,,"3106","3106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IFR CA IV DPPLR VELCTY/PRSSRE  ADDL VSLS LIMITED","30900220","CDM","481","RC","93572","HCPCS",,,"facility","outpatient",,,,"3106","3106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INITIATION VENOUS","30900223","CDM","361","RC","33946","HCPCS",,,"facility","inpatient",,,,"16405","16405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INITIATION VENOUS","30900223","CDM","361","RC","33946","HCPCS",,,"facility","outpatient",,,,"16405","16405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INITIATION ARTERY","30900224","CDM","361","RC","33947","HCPCS",,,"facility","inpatient",,,,"17539","17539",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECMO/ECLS INITIATION ARTERY","30900224","CDM","361","RC","33947","HCPCS",,,"facility","outpatient",,,,"17539","17539",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRANSCATH CLSR L ATR APNDGE","30900229","CDM","361","RC","33340","HCPCS",,,"facility","inpatient",,,,"43773","43773",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PERQ TRANSCATH CLSR L ATR APNDGE","30900229","CDM","361","RC","33340","HCPCS",,,"facility","outpatient",,,,"43773","43773",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRACTIONAL FLOW RESERVE EVAL OF CORONARY ARTERY","30900233","CDM","480","RC","93799","HCPCS",,,"facility","inpatient",,,,"725","725",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRACTIONAL FLOW RESERVE EVAL OF CORONARY ARTERY","30900233","CDM","480","RC","93799","HCPCS",,,"facility","outpatient",,,,"725","725",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLECAINIDE CHALLENGE","30900234","CDM","480","RC","93799","HCPCS",,,"facility","inpatient",,,,"754","754",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLECAINIDE CHALLENGE","30900234","CDM","480","RC","93799","HCPCS",,,"facility","outpatient",,,,"754","754",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRACARDIAC ECHOCARDIOGRAPHY","30900236","CDM","480","RC","93799","HCPCS",,,"facility","inpatient",,,,"8102","8102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRACARDIAC ECHOCARDIOGRAPHY","30900236","CDM","480","RC","93799","HCPCS",,,"facility","outpatient",,,,"8102","8102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ISUPREL INFUSION","30900237","CDM","480","RC","93799","HCPCS",,,"facility","inpatient",,,,"754","754",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ISUPREL INFUSION","30900237","CDM","480","RC","93799","HCPCS",,,"facility","outpatient",,,,"754","754",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RT HEART CATH IMPL PRESSURE SENSOR","30900241","CDM","481","RC","33289","HCPCS",,,"facility","inpatient",,,,"84476","84476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RT HEART CATH IMPL PRESSURE SENSOR","30900241","CDM","481","RC","33289","HCPCS",,,"facility","outpatient",,,,"84476","84476",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BASILICA","30900242","CDM","480","RC","93799","HCPCS",,,"facility","inpatient",,,,"15712","15712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BASILICA","30900242","CDM","480","RC","93799","HCPCS",,,"facility","outpatient",,,,"15712","15712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TAVR, OPEN CAROTID APPROACH","30900244","CDM","361","RC","33999","HCPCS",,,"facility","inpatient",,,,"11066","11066",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TAVR, OPEN CAROTID APPROACH","30900244","CDM","361","RC","33999","HCPCS",,,"facility","outpatient",,,,"11066","11066",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TTVR PERQ APPR 1ST PROSTH","30900245","CDM","361","RC","0569T","HCPCS",,,"facility","inpatient",,,,"53609","53609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TTVR PERQ APPR 1ST PROSTH","30900245","CDM","361","RC","0569T","HCPCS",,,"facility","outpatient",,,,"53609","53609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TTVR PERQ EA ADDL PROSTH","30900246","CDM","361","RC","0570T","HCPCS",,,"facility","inpatient",,,,"27730","27730",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TTVR PERQ EA ADDL PROSTH","30900246","CDM","361","RC","0570T","HCPCS",,,"facility","outpatient",,,,"27730","27730",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATH MITRL VALVE REPLACE","30900249","CDM","361","RC","0544T","HCPCS",,,"facility","inpatient",,,,"72379","72379",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATH MITRL VALVE REPLACE","30900249","CDM","361","RC","0544T","HCPCS",,,"facility","outpatient",,,,"72379","72379",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATH TRICUS VALVE REPLACE","30900250","CDM","361","RC","0545T","HCPCS",,,"facility","inpatient",,,,"61059","61059",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATH TRICUS VALVE REPLACE","30900250","CDM","361","RC","0545T","HCPCS",,,"facility","outpatient",,,,"61059","61059",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LAMPOON PROCEDURE","30900251","CDM","480","RC","93799","HCPCS",,,"facility","inpatient",,,,"15712","15712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LAMPOON PROCEDURE","30900251","CDM","480","RC","93799","HCPCS",,,"facility","outpatient",,,,"15712","15712",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TAS CONGENITAL CARDIAC ANOMALIES ANY METHOD","30900252","CDM","361","RC","33741","HCPCS",,,"facility","inpatient",,,,"24257","24257",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TAS CONGENITAL CARDIAC ANOMALIES ANY METHOD","30900252","CDM","361","RC","33741","HCPCS",,,"facility","outpatient",,,,"24257","24257",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIS CRTJ ST CONGENITAL CARDIAC ANOMAL 1ST SHUNT","30900253","CDM","361","RC","33745","HCPCS",,,"facility","inpatient",,,,"14370","14370",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIS CRTJ ST CONGENITAL CARDIAC ANOMAL 1ST SHUNT","30900253","CDM","361","RC","33745","HCPCS",,,"facility","outpatient",,,,"14370","14370",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIS CRTJ ST CONGENITAL CARDIAC ANOMAL EA ADDL","30900254","CDM","361","RC","33746","HCPCS",,,"facility","inpatient",,,,"5655","5655",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIS CRTJ ST CONGENITAL CARDIAC ANOMAL EA ADDL","30900254","CDM","361","RC","33746","HCPCS",,,"facility","outpatient",,,,"5655","5655",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSJ PERQ VAD W/RS&I R HEART VENOUS ACCESS ONLY","30900255","CDM","361","RC","33995","HCPCS",,,"facility","inpatient",,,,"2032","2032",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSJ PERQ VAD W/RS&I R HEART VENOUS ACCESS ONLY","30900255","CDM","361","RC","33995","HCPCS",,,"facility","outpatient",,,,"2032","2032",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMVL PERQ R HEART VAD VENOUS CANNULA SEP INSJ","30900256","CDM","361","RC","33997","HCPCS",,,"facility","inpatient",,,,"1978","1978",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RMVL PERQ R HEART VAD VENOUS CANNULA SEP INSJ","30900256","CDM","361","RC","33997","HCPCS",,,"facility","outpatient",,,,"1978","1978",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TCAT RMVL/DBLK ICAR MAS PERQ","30900257","CDM","481","RC","0644T","HCPCS",,,"facility","inpatient",,,,"19949","19949",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TCAT RMVL/DBLK ICAR MAS PERQ","30900257","CDM","481","RC","0644T","HCPCS",,,"facility","outpatient",,,,"19949","19949",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TTVI/RPLCMT W/PRSTC VLV PERQ","30900258","CDM","481","RC","0646T","HCPCS",,,"facility","inpatient",,,,"65515","65515",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TTVI/RPLCMT W/PRSTC VLV PERQ","30900258","CDM","481","RC","0646T","HCPCS",,,"facility","outpatient",,,,"65515","65515",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R HRT CATH CHD W/IMG NML NT CNJ","30900261","CDM","481","RC","93593","HCPCS",,,"facility","inpatient",,,,"11094","11094",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R HRT CATH CHD W/IMG NML NT CNJ","30900261","CDM","481","RC","93593","HCPCS",,,"facility","outpatient",,,,"11094","11094",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R HRT CATH CHD W/IMG ABNL NT CNJ","30900262","CDM","481","RC","93594","HCPCS",,,"facility","inpatient",,,,"17486","17486",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R HRT CATH CHD W/IMG ABNL NT CNJ","30900262","CDM","481","RC","93594","HCPCS",,,"facility","outpatient",,,,"17486","17486",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R&L HRT CATH CHD W/IMG CATH NML NT CNJ","30900263","CDM","481","RC","93596","HCPCS",,,"facility","inpatient",,,,"28030","28030",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA R&L HRT CATH CHD W/IMG CATH NML NT CNJ","30900263","CDM","481","RC","93596","HCPCS",,,"facility","outpatient",,,,"28030","28030",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT PLMT&RMVL CEPD PERQ","30900265","CDM","361","RC","33370","HCPCS",,,"facility","inpatient",,,,"28241","28241",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT PLMT&RMVL CEPD PERQ","30900265","CDM","361","RC","33370","HCPCS",,,"facility","outpatient",,,,"28241","28241",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CAR OUTP MEAS DRG CATH CHD","30900267","CDM","481","RC","93598","HCPCS",,,"facility","inpatient",,,,"1975","1975",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CAR OUTP MEAS DRG CATH CHD","30900267","CDM","481","RC","93598","HCPCS",,,"facility","outpatient",,,,"1975","1975",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NON CONGENITAL ATRIAL SEPTOSTOMY","30900268","CDM","361","RC","33999","HCPCS",,,"facility","inpatient",,,,"19534","19534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NON CONGENITAL ATRIAL SEPTOSTOMY","30900268","CDM","361","RC","33999","HCPCS",,,"facility","outpatient",,,,"19534","19534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NON CONGENTIAL VSD CLOSURE","30900269","CDM","480","RC","93799","HCPCS",,,"facility","inpatient",,,,"38128","38128",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NON CONGENTIAL VSD CLOSURE","30900269","CDM","480","RC","93799","HCPCS",,,"facility","outpatient",,,,"38128","38128",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRLUML CORONRY LITHOTRP","30900284","CDM","480","RC","92972","HCPCS",,,"facility","inpatient",,,,"18927","18927",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRLUML CORONRY LITHOTRP","30900284","CDM","480","RC","92972","HCPCS",,,"facility","outpatient",,,,"18927","18927",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT INS 1CHMBR LDLS PM RA","30900293","CDM","481","RC","0823T","HCPCS",,,"facility","inpatient",,,,"70315","70315",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT INS 1CHMBR LDLS PM RA","30900293","CDM","481","RC","0823T","HCPCS",,,"facility","outpatient",,,,"70315","70315",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT RMV 1CHMBR LDLS PM RA","30900294","CDM","481","RC","0824T","HCPCS",,,"facility","inpatient",,,,"11275","11275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT RMV 1CHMBR LDLS PM RA","30900294","CDM","481","RC","0824T","HCPCS",,,"facility","outpatient",,,,"11275","11275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT INS 2CHMBR LDLS PM CMPL","30900297","CDM","481","RC","0795T","HCPCS",,,"facility","inpatient",,,,"95378","95378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT INS 2CHMBR LDLS PM CMPL","30900297","CDM","481","RC","0795T","HCPCS",,,"facility","outpatient",,,,"95378","95378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT INS 2CHMBR LDLS PM RA","30900298","CDM","481","RC","0796T","HCPCS",,,"facility","inpatient",,,,"105447","105447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT INS 2CHMBR LDLS PM RA","30900298","CDM","481","RC","0796T","HCPCS",,,"facility","outpatient",,,,"105447","105447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT INS 2CHMBR LDLS PM RV","30900299","CDM","481","RC","0797T","HCPCS",,,"facility","inpatient",,,,"77763","77763",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT INS 2CHMBR LDLS PM RV","30900299","CDM","481","RC","0797T","HCPCS",,,"facility","outpatient",,,,"77763","77763",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT RMVL 2CHMBR LDLS PM RV","30900302","CDM","481","RC","0800T","HCPCS",,,"facility","inpatient",,,,"13529","13529",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT RMVL 2CHMBR LDLS PM RV","30900302","CDM","481","RC","0800T","HCPCS",,,"facility","outpatient",,,,"13529","13529",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT RMV&RPL2CHMB LDLS PM RA","30900304","CDM","481","RC","0802T","HCPCS",,,"facility","inpatient",,,,"11275","11275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TCAT RMV&RPL2CHMB LDLS PM RA","30900304","CDM","481","RC","0802T","HCPCS",,,"facility","outpatient",,,,"11275","11275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ TCAT THER RX NTRAC BALO1","30900308","CDM","481","RC","0913T","HCPCS",,,"facility","inpatient",,,,"29951","29951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ TCAT THER RX NTRAC BALO1","30900308","CDM","481","RC","0913T","HCPCS",,,"facility","outpatient",,,,"29951","29951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ TCAT THR RX NTRC BAL SEP","30900309","CDM","481","RC","0914T","HCPCS",,,"facility","inpatient",,,,"24526","24526",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PRQ TCAT THR RX NTRC BAL SEP","30900309","CDM","481","RC","0914T","HCPCS",,,"facility","outpatient",,,,"24526","24526",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATHETER RENAL SYMPATH DENERVATION UNILAT","30900310","CDM","481","RC","0338T","HCPCS",,,"facility","inpatient",,,,"23542","23542",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATHETER RENAL SYMPATH DENERVATION UNILAT","30900310","CDM","481","RC","0338T","HCPCS",,,"facility","outpatient",,,,"23542","23542",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATHETER RENAL SYMPATH DENERVATION BILAT","30900311","CDM","481","RC","0339T","HCPCS",,,"facility","inpatient",,,,"35313","35313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATHETER RENAL SYMPATH DENERVATION BILAT","30900311","CDM","481","RC","0339T","HCPCS",,,"facility","outpatient",,,,"35313","35313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATHETER MYOTOMY (SESAME)","30900314","CDM","361","RC","33999","HCPCS",,,"facility","inpatient",,,,"39010","39010",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSCATHETER MYOTOMY (SESAME)","30900314","CDM","361","RC","33999","HCPCS",,,"facility","outpatient",,,,"39010","39010",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TEMP TRANSCUTANEOUS PACING","32000000","CDM","480","RC","92953","HCPCS",,,"facility","inpatient",,,,"2581","2581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TEMP TRANSCUTANEOUS PACING","32000000","CDM","480","RC","92953","HCPCS",,,"facility","outpatient",,,,"2581","2581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CARDIOVERSION ELECTRIC EXTERNAL","32000001","CDM","480","RC","92960","HCPCS",,,"facility","inpatient",,,,"4349","4349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CARDIOVERSION ELECTRIC EXTERNAL","32000001","CDM","480","RC","92960","HCPCS",,,"facility","outpatient",,,,"4349","4349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CARDIOVERSION INTERNAL","32000002","CDM","480","RC","92961","HCPCS",,,"facility","inpatient",,,,"4959","4959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CARDIOVERSION INTERNAL","32000002","CDM","480","RC","92961","HCPCS",,,"facility","outpatient",,,,"4959","4959",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG 12 LEAD TRACING ONLY","32000003","CDM","730","RC","93005","HCPCS",,,"facility","inpatient",,,,"614","614",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG 12 LEAD TRACING ONLY","32000003","CDM","730","RC","93005","HCPCS",,,"facility","outpatient",,,,"614","614",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CARDIAC STRESS TEST","32000006","CDM","482","RC","93017","HCPCS",,,"facility","inpatient",,,,"2345","2345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CARDIAC STRESS TEST","32000006","CDM","482","RC","93017","HCPCS",,,"facility","outpatient",,,,"2345","2345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ERGONOVINE PROVOCATION TEST","32000007","CDM","730","RC","93024","HCPCS",,,"facility","inpatient",,,,"1405","1405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ERGONOVINE PROVOCATION TEST","32000007","CDM","730","RC","93024","HCPCS",,,"facility","outpatient",,,,"1405","1405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG 1-3 LEAD TRACING ONLY","32000008","CDM","730","RC","93041","HCPCS",,,"facility","inpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG 1-3 LEAD TRACING ONLY","32000008","CDM","730","RC","93041","HCPCS",,,"facility","outpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG UP TO 48HRS WITH SCANNING RECORDING","32000009","CDM","731","RC","93225","HCPCS",,,"facility","inpatient",,,,"749","749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG UP TO 48HRS WITH SCANNING RECORDING","32000009","CDM","731","RC","93225","HCPCS",,,"facility","outpatient",,,,"749","749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG UP TO 48 HRS WITH SCANNING ANALYSIS AND REPORT","32000010","CDM","731","RC","93226","HCPCS",,,"facility","inpatient",,,,"947","947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG UP TO 48 HRS WITH SCANNING ANALYSIS AND REPORT","32000010","CDM","731","RC","93226","HCPCS",,,"facility","outpatient",,,,"947","947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVENT MONITOR HOOK UP AND RECORDING/DISCONNECT","32000013","CDM","731","RC","93270","HCPCS",,,"facility","inpatient",,,,"461","461",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EVENT MONITOR HOOK UP AND RECORDING/DISCONNECT","32000013","CDM","731","RC","93270","HCPCS",,,"facility","outpatient",,,,"461","461",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXT PT ACTVTD ECG REC DWNLD UP TO 30 DAY 24H ATT","32000014","CDM","731","RC","93271","HCPCS",,,"facility","inpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXT PT ACTVTD ECG REC DWNLD UP TO 30 DAY 24H ATT","32000014","CDM","731","RC","93271","HCPCS",,,"facility","outpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG SIGNAL AVERAGED","32000015","CDM","730","RC","93278","HCPCS",,,"facility","inpatient",,,,"2419","2419",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EKG SIGNAL AVERAGED","32000015","CDM","730","RC","93278","HCPCS",,,"facility","outpatient",,,,"2419","2419",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D CONGENITAL ANOMALY COMPLETE","32000016","CDM","483","RC","93303","HCPCS",,,"facility","inpatient",,,,"1469","1469",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D CONGENITAL ANOMALY COMPLETE","32000016","CDM","483","RC","93303","HCPCS",,,"facility","outpatient",,,,"1469","1469",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D CONGENITAL ANOMALY LIMITED","32000017","CDM","483","RC","93304","HCPCS",,,"facility","inpatient",,,,"979","979",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D CONGENITAL ANOMALY LIMITED","32000017","CDM","483","RC","93304","HCPCS",,,"facility","outpatient",,,,"979","979",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D COMPLETE","32000018","CDM","483","RC","93307","HCPCS",,,"facility","inpatient",,,,"2776","2776",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D COMPLETE","32000018","CDM","483","RC","93307","HCPCS",,,"facility","outpatient",,,,"2776","2776",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D LIMITED","32000019","CDM","483","RC","93308","HCPCS",,,"facility","inpatient",,,,"1923","1923",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D LIMITED","32000019","CDM","483","RC","93308","HCPCS",,,"facility","outpatient",,,,"1923","1923",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECHO TRANSESOPHAGEAL","32000020","CDM","483","RC","93312","HCPCS",,,"facility","inpatient",,,,"5451","5451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECHO TRANSESOPHAGEAL","32000020","CDM","483","RC","93312","HCPCS",,,"facility","outpatient",,,,"5451","5451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO DOPPLER COMPLETE","32000022","CDM","483","RC","93320","HCPCS",,,"facility","inpatient",,,,"1643","1643",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO DOPPLER COMPLETE","32000022","CDM","483","RC","93320","HCPCS",,,"facility","outpatient",,,,"1643","1643",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO DOPPLER LIMITED","32000023","CDM","483","RC","93321","HCPCS",,,"facility","inpatient",,,,"1157","1157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO DOPPLER LIMITED","32000023","CDM","483","RC","93321","HCPCS",,,"facility","outpatient",,,,"1157","1157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO DOPPLER COLOR FLOW","32000024","CDM","483","RC","93325","HCPCS",,,"facility","inpatient",,,,"1256","1256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO DOPPLER COLOR FLOW","32000024","CDM","483","RC","93325","HCPCS",,,"facility","outpatient",,,,"1256","1256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D STRESS WO CON","32000025","CDM","483","RC","93350","HCPCS",,,"facility","inpatient",,,,"4326","4326",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2-D STRESS WO CON","32000025","CDM","483","RC","93350","HCPCS",,,"facility","outpatient",,,,"4326","4326",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PACEMAKER DUAL INTERROGAT WO REPROGRAMM","32000026","CDM","480","RC","93280","HCPCS",,,"facility","inpatient",,,,"284","284",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PACEMAKER DUAL INTERROGAT WO REPROGRAMM","32000026","CDM","480","RC","93280","HCPCS",,,"facility","outpatient",,,,"284","284",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TRNSVNS ICD EVAL REPROGRAM 2 LEAD SYS","32000030","CDM","480","RC","93283","HCPCS",,,"facility","inpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TRNSVNS ICD EVAL REPROGRAM 2 LEAD SYS","32000030","CDM","480","RC","93283","HCPCS",,,"facility","outpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CPR","32000032","CDM","480","RC","92950","HCPCS",,,"facility","inpatient",,,,"2909","2909",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA CPR","32000032","CDM","480","RC","92950","HCPCS",,,"facility","outpatient",,,,"2909","2909",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO TRANSESOPHAGEAL CONGENITAL ANOMALY","32000033","CDM","483","RC","93315","HCPCS",,,"facility","inpatient",,,,"5480","5480",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO TRANSESOPHAGEAL CONGENITAL ANOMALY","32000033","CDM","483","RC","93315","HCPCS",,,"facility","outpatient",,,,"5480","5480",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECHO TRANSESOPHAGEAL MONITORING","32000034","CDM","483","RC","93318","HCPCS",,,"facility","inpatient",,,,"5606","5606",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECHO TRANSESOPHAGEAL MONITORING","32000034","CDM","483","RC","93318","HCPCS",,,"facility","outpatient",,,,"5606","5606",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRACARDIAC ECHO DURING INTERVENTION","32000036","CDM","480","RC","93662","HCPCS",,,"facility","inpatient",,,,"10070","10070",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA INTRACARDIAC ECHO DURING INTERVENTION","32000036","CDM","480","RC","93662","HCPCS",,,"facility","outpatient",,,,"10070","10070",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ELEC ANALYSIS ANTITACHYCARDIA PACEMAKER SYS","32000038","CDM","480","RC","93724","HCPCS",,,"facility","inpatient",,,,"2314","2314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ELEC ANALYSIS ANTITACHYCARDIA PACEMAKER SYS","32000038","CDM","480","RC","93724","HCPCS",,,"facility","outpatient",,,,"2314","2314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL","32000041","CDM","480","RC","93293","HCPCS",,,"facility","inpatient",,,,"2635","2635",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL","32000041","CDM","480","RC","93293","HCPCS",,,"facility","outpatient",,,,"2635","2635",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2D COM TRNS W/CON","32000045","CDM","483","RC","C8923","HCPCS",,,"facility","inpatient",,,,"3595","3595",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2D COM TRNS W/CON","32000045","CDM","483","RC","C8923","HCPCS",,,"facility","outpatient",,,,"3595","3595",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2D LTD TRNS W/CON","32000046","CDM","483","RC","C8924","HCPCS",,,"facility","inpatient",,,,"2243","2243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2D LTD TRNS W/CON","32000046","CDM","483","RC","C8924","HCPCS",,,"facility","outpatient",,,,"2243","2243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2D TEE W/CON","32000047","CDM","483","RC","C8925","HCPCS",,,"facility","inpatient",,,,"5279","5279",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2D TEE W/CON","32000047","CDM","483","RC","C8925","HCPCS",,,"facility","outpatient",,,,"5279","5279",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO TEE W/CON MONTRNG","32000049","CDM","483","RC","C8927","HCPCS",,,"facility","inpatient",,,,"17432","17432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO TEE W/CON MONTRNG","32000049","CDM","483","RC","C8927","HCPCS",,,"facility","outpatient",,,,"17432","17432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2D W STRESS W/CON","32000050","CDM","483","RC","C8928","HCPCS",,,"facility","inpatient",,,,"4242","4242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO 2D W STRESS W/CON","32000050","CDM","483","RC","C8928","HCPCS",,,"facility","outpatient",,,,"4242","4242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TTE W/DOPPLER COMPLETE","32000074","CDM","483","RC","93306","HCPCS",,,"facility","inpatient",,,,"4223","4223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TTE W/DOPPLER COMPLETE","32000074","CDM","483","RC","93306","HCPCS",,,"facility","outpatient",,,,"4223","4223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO TTE 2D W/WO M-MODE REST&STRS CONT ECG","32000075","CDM","483","RC","93351","HCPCS",,,"facility","inpatient",,,,"4329","4329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA ECHO TTE 2D W/WO M-MODE REST&STRS CONT ECG","32000075","CDM","483","RC","93351","HCPCS",,,"facility","outpatient",,,,"4006","4006",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TTE W OR W/O FOL W/CONTR DOPPLER","32000077","CDM","483","RC","C8929","HCPCS",,,"facility","inpatient",,,,"5934","5934",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TTE W OR W/O FOL W/CONTR DOPPLER","32000077","CDM","483","RC","C8929","HCPCS",,,"facility","outpatient",,,,"5934","5934",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TTE W OR W/O CONTR CONT ECG","32000078","CDM","483","RC","C8930","HCPCS",,,"facility","inpatient",,,,"6498","6498",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA TTE W OR W/O CONTR CONT ECG","32000078","CDM","483","RC","C8930","HCPCS",,,"facility","outpatient",,,,"6498","6498",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECHO TEE 3D W/CON & REPORT DOPPLER","32000097","CDM","483","RC","93355","HCPCS",,,"facility","inpatient",,,,"6639","6639",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ECHO TEE 3D W/CON & REPORT DOPPLER","32000097","CDM","483","RC","93355","HCPCS",,,"facility","outpatient",,,,"6639","6639",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH CLS MITRAL","32000103","CDM","480","RC","93590","HCPCS",,,"facility","inpatient",,,,"67884","67884",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH CLS MITRAL","32000103","CDM","480","RC","93590","HCPCS",,,"facility","outpatient",,,,"67884","67884",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH CLS AORTIC","32000104","CDM","480","RC","93591","HCPCS",,,"facility","inpatient",,,,"77327","77327",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH CLS AORTIC","32000104","CDM","480","RC","93591","HCPCS",,,"facility","outpatient",,,,"77327","77327",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH CLOSURE EACH","32000105","CDM","480","RC","93592","HCPCS",,,"facility","inpatient",,,,"24357","24357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA PERQ TRANSCATH CLOSURE EACH","32000105","CDM","480","RC","93592","HCPCS",,,"facility","outpatient",,,,"24357","24357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA HEARTFLOW FFRCT COR FFR DATA PREP & TRANSMIS","32000107","CDM","480","RC","0502T","HCPCS",,,"facility","inpatient",,,,"66","66",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA HEARTFLOW FFRCT COR FFR DATA PREP & TRANSMIS","32000107","CDM","480","RC","0502T","HCPCS",,,"facility","outpatient",,,,"66","66",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA HEARTFLOW FFRCT COR FFR ALYS & GNRJ FFR MDL","32000108","CDM","480","RC","0503T","HCPCS",,,"facility","inpatient",,,,"5700","5700",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA HEARTFLOW FFRCT COR FFR ALYS & GNRJ FFR MDL","32000108","CDM","480","RC","0503T","HCPCS",,,"facility","outpatient",,,,"5700","5700",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MYOCRD STRAIN IMG SPCKL TRCK","32000113","CDM","483","RC","93356","HCPCS",,,"facility","inpatient",,,,"1025","1025",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MYOCRD STRAIN IMG SPCKL TRCK","32000113","CDM","483","RC","93356","HCPCS",,,"facility","outpatient",,,,"1025","1025",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXTERNAL ECG REC>48HR<7D RECORDING","32000114","CDM","731","RC","93242","HCPCS",,,"facility","inpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXTERNAL ECG REC>48HR<7D RECORDING","32000114","CDM","731","RC","93242","HCPCS",,,"facility","outpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXTERNAL ECG REC>7D<15D RECORDING","32000116","CDM","731","RC","93246","HCPCS",,,"facility","inpatient",,,,"402","402",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXTERNAL ECG REC>7D<15D RECORDING","32000116","CDM","731","RC","93246","HCPCS",,,"facility","outpatient",,,,"402","402",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA 3D ECHO IMG TEE/TTE CGEN CAR ANOMAL","32000119","CDM","483","RC","93319","HCPCS",,,"facility","inpatient",,,,"1357","1357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA 3D ECHO IMG TEE/TTE CGEN CAR ANOMAL","32000119","CDM","483","RC","93319","HCPCS",,,"facility","outpatient",,,,"1357","1357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA N-INVAS EST C FFR SW ALY CTA","32000121","CDM","480","RC","75580","HCPCS",,,"facility","inpatient",,,,"5761","5761",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CTA N-INVAS EST C FFR SW ALY CTA","32000121","CDM","480","RC","75580","HCPCS",,,"facility","outpatient",,,,"5761","5761",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIAC REHAB WO EKG","32100003","CDM","943","RC","93797","HCPCS",,,"facility","inpatient",,,,"394","394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIAC REHAB WO EKG","32100003","CDM","943","RC","93797","HCPCS",,,"facility","outpatient",,,,"394","394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY CARDIAC REHAB PHASE 3 ORIENTATION","32100004","CDM",,,,,,,"facility","inpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY CARDIAC REHAB PHASE 3 ORIENTATION","32100004","CDM",,,,,,,"facility","outpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIAC REHAB W CONT MONITORING EA SESSION","32100006","CDM","943","RC","93798","HCPCS",,,"facility","inpatient",,,,"465","465",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIAC REHAB W CONT MONITORING EA SESSION","32100006","CDM","943","RC","93798","HCPCS",,,"facility","outpatient",,,,"465","465",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMOKING CESSATION COUNSELING 3-10 M","32100007","CDM","942","RC","99406","HCPCS",,,"facility","inpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMOKING CESSATION COUNSELING 3-10 M","32100007","CDM","942","RC","99406","HCPCS",,,"facility","outpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMOKING CESSATION COUNSELING >10 M","32100008","CDM","942","RC","99407","HCPCS",,,"facility","inpatient",,,,"159","159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMOKING CESSATION COUNSELING >10 M","32100008","CDM","942","RC","99407","HCPCS",,,"facility","outpatient",,,,"159","159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT INITIAL HF","33000000","CDM","410","RC","94002","HCPCS",,,"facility","inpatient",,,,"5784","5784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT INITIAL HF","33000000","CDM","410","RC","94002","HCPCS",,,"facility","outpatient",,,,"5784","5784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT INITIAL ADULT","33000002","CDM","410","RC","94002","HCPCS",,,"facility","inpatient",,,,"5784","5784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT INITIAL ADULT","33000002","CDM","410","RC","94002","HCPCS",,,"facility","outpatient",,,,"5784","5784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT INITIAL NEO/PEDS","33000003","CDM","410","RC","94002","HCPCS",,,"facility","inpatient",,,,"5784","5784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT INITIAL NEO/PEDS","33000003","CDM","410","RC","94002","HCPCS",,,"facility","outpatient",,,,"5784","5784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT SUBSEQUENT HF","33000004","CDM","410","RC","94003","HCPCS",,,"facility","inpatient",,,,"4298","4298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT SUBSEQUENT HF","33000004","CDM","410","RC","94003","HCPCS",,,"facility","outpatient",,,,"4298","4298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT SUBSEQUENT NEO/PEDS","33000005","CDM","410","RC","94003","HCPCS",,,"facility","inpatient",,,,"4298","4298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT SUBSEQUENT NEO/PEDS","33000005","CDM","410","RC","94003","HCPCS",,,"facility","outpatient",,,,"4298","4298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT SUBSEQUENT ADULT","33000007","CDM","410","RC","94003","HCPCS",,,"facility","inpatient",,,,"4298","4298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT SUBSEQUENT ADULT","33000007","CDM","410","RC","94003","HCPCS",,,"facility","outpatient",,,,"4298","4298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPPB TREATMENT SUBSEQUENT","33000008","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPPB TREATMENT SUBSEQUENT","33000008","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPV TREATMENT SUBSEQUENT","33000009","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPV TREATMENT SUBSEQUENT","33000009","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AIRWAY INHALATION TREATMENT","33000010","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AIRWAY INHALATION TREATMENT","33000010","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONTINUOUS BREATHING TREATMENT 1ST HOUR","33000011","CDM","410","RC","94644","HCPCS",,,"facility","inpatient",,,,"690","690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONTINUOUS BREATHING TREATMENT 1ST HOUR","33000011","CDM","410","RC","94644","HCPCS",,,"facility","outpatient",,,,"690","690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIPAP/CPAP/AVAPS SUBSEQUENT DAY","33000012","CDM","410","RC","94660","HCPCS",,,"facility","inpatient",,,,"2733","2733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIPAP/CPAP/AVAPS SUBSEQUENT DAY","33000012","CDM","410","RC","94660","HCPCS",,,"facility","outpatient",,,,"2733","2733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIPAP/CPAP/AVAPS INITIAL DAY","33000013","CDM","410","RC","94660","HCPCS",,,"facility","inpatient",,,,"2733","2733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIPAP/CPAP/AVAPS INITIAL DAY","33000013","CDM","410","RC","94660","HCPCS",,,"facility","outpatient",,,,"2733","2733",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT CNP INITIAL DAY","33000014","CDM","410","RC","94662","HCPCS",,,"facility","outpatient",,,,"8255","8255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPV TREATMENT DEMO/EVAL","33000015","CDM","412","RC","94664","HCPCS",,,"facility","inpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPV TREATMENT DEMO/EVAL","33000015","CDM","412","RC","94664","HCPCS",,,"facility","outpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEST PHYSIOTHERAPY INITIAL","33000016","CDM","410","RC","94667","HCPCS",,,"facility","inpatient",,,,"418","418",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEST PHYSIOTHERAPY INITIAL","33000016","CDM","410","RC","94667","HCPCS",,,"facility","outpatient",,,,"418","418",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEST PHYSIOTHERAPY SUBSEQUENT","33000017","CDM","410","RC","94668","HCPCS",,,"facility","inpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEST PHYSIOTHERAPY SUBSEQUENT","33000017","CDM","410","RC","94668","HCPCS",,,"facility","outpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC PROCEDURE STRENGTH/ENDURANCE 15MIN","33000019","CDM","419","RC","G0237","HCPCS",,,"facility","inpatient",,,,"188","188",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC PROCEDURE STRENGTH/ENDURANCE 15MIN","33000019","CDM","419","RC","G0237","HCPCS",,,"facility","outpatient",,,,"188","188",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC PROCEDURE RESPIRATORY FUNCTION 15MIN","33000020","CDM","419","RC","G0238","HCPCS",,,"facility","inpatient",,,,"191","191",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC PROCEDURE RESPIRATORY FUNCTION 15MIN","33000020","CDM","419","RC","G0238","HCPCS",,,"facility","outpatient",,,,"191","191",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC PROCEDURE RESPIRATORY FUNCTION GROUP","33000021","CDM","419","RC","G0239","HCPCS",,,"facility","inpatient",,,,"313","313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC PROCEDURE RESPIRATORY FUNCTION GROUP","33000021","CDM","419","RC","G0239","HCPCS",,,"facility","outpatient",,,,"313","313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PENTAMIDINE NEBULIZATION TX","33000022","CDM","412","RC","94642","HCPCS",,,"facility","inpatient",,,,"409","409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PENTAMIDINE NEBULIZATION TX","33000022","CDM","412","RC","94642","HCPCS",,,"facility","outpatient",,,,"409","409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEROSOL TREATMENT DEMO/EVAL","33000023","CDM","412","RC","94664","HCPCS",,,"facility","inpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEROSOL TREATMENT DEMO/EVAL","33000023","CDM","412","RC","94664","HCPCS",,,"facility","outpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPPB TREATMENT DEMO/EVAL","33000025","CDM","412","RC","94664","HCPCS",,,"facility","inpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPPB TREATMENT DEMO/EVAL","33000025","CDM","412","RC","94664","HCPCS",,,"facility","outpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MDI/NEB DEMO/EVAL","33000026","CDM","412","RC","94664","HCPCS",,,"facility","inpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MDI/NEB DEMO/EVAL","33000026","CDM","412","RC","94664","HCPCS",,,"facility","outpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEROSOL TREATMENT SUBSEQUENT","33000027","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEROSOL TREATMENT SUBSEQUENT","33000027","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONTINUOUS BREATHING TREATMENT EACH ADDITIONAL HOUR","33000028","CDM","410","RC","94645","HCPCS",,,"facility","inpatient",,,,"373","373",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONTINUOUS BREATHING TREATMENT EACH ADDITIONAL HOUR","33000028","CDM","410","RC","94645","HCPCS",,,"facility","outpatient",,,,"373","373",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUCTION NASOTRACHEAL","33000029","CDM","410","RC","31720","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUCTION NASOTRACHEAL","33000029","CDM","410","RC","31720","HCPCS",,,"facility","outpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MDI/NEBULIZER TREATMENT SUBSEQUENT","33000030","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MDI/NEBULIZER TREATMENT SUBSEQUENT","33000030","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENT MANAGEMENT CNP SUBSEQUENT DAY","33000031","CDM","410","RC","94662","HCPCS",,,"facility","outpatient",,,,"8255","8255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURFACTANT ADMN THRU TUBE","33000032","CDM","460","RC","94610","HCPCS",,,"facility","inpatient",,,,"427","427",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURFACTANT ADMN THRU TUBE","33000032","CDM","460","RC","94610","HCPCS",,,"facility","outpatient",,,,"427","427",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLETHYSMOGRAPHY LUNG VOL","33000034","CDM","460","RC","94726","HCPCS",,,"facility","inpatient",,,,"992","992",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLETHYSMOGRAPHY LUNG VOL","33000034","CDM","460","RC","94726","HCPCS",,,"facility","outpatient",,,,"992","992",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAR SEAT/BED TEST 60 MIN","33000037","CDM","460","RC","94780","HCPCS",,,"facility","inpatient",,,,"746","746",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAR SEAT/BED TEST 60 MIN","33000037","CDM","460","RC","94780","HCPCS",,,"facility","outpatient",,,,"746","746",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAR SEAT/BED TEST +30 MIN","33000038","CDM","460","RC","94781","HCPCS",,,"facility","inpatient",,,,"329","329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAR SEAT/BED TEST +30 MIN","33000038","CDM","460","RC","94781","HCPCS",,,"facility","outpatient",,,,"329","329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTROESOPH REFLUX TEST","33000039","CDM","929","RC","91034","HCPCS",,,"facility","inpatient",,,,"3840","3840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTROESOPH REFLUX TEST","33000039","CDM","929","RC","91034","HCPCS",,,"facility","outpatient",,,,"3840","3840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MECHANICAL CHEST WALL OSCILL","33000042","CDM","410","RC","94669","HCPCS",,,"facility","inpatient",,,,"502","502",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MECHANICAL CHEST WALL OSCILL","33000042","CDM","410","RC","94669","HCPCS",,,"facility","outpatient",,,,"502","502",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXERCISE TEST BRNCSPSM W/ ECG","33000044","CDM","460","RC","94617","HCPCS",,,"facility","inpatient",,,,"632","632",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXERCISE TEST BRNCSPSM W/ ECG","33000044","CDM","460","RC","94617","HCPCS",,,"facility","outpatient",,,,"632","632",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PULMONARY STRESS TEST/6 MINUTE WALK","33000045","CDM","460","RC","94618","HCPCS",,,"facility","inpatient",,,,"662","662",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PULMONARY STRESS TEST/6 MINUTE WALK","33000045","CDM","460","RC","94618","HCPCS",,,"facility","outpatient",,,,"662","662",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PEP THERAPY","33000046","CDM","412","RC","94664","HCPCS",,,"facility","inpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PEP THERAPY","33000046","CDM","412","RC","94664","HCPCS",,,"facility","outpatient",,,,"555","555",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COUGH ASSIST","33000047","CDM","460","RC","94799","HCPCS",,,"facility","inpatient",,,,"308","308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COUGH ASSIST","33000047","CDM","460","RC","94799","HCPCS",,,"facility","outpatient",,,,"308","308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXERCISE TEST BRNCSPSM W/O ECG","33000049","CDM","460","RC","94619","HCPCS",,,"facility","inpatient",,,,"204","204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXERCISE TEST BRNCSPSM W/O ECG","33000049","CDM","460","RC","94619","HCPCS",,,"facility","outpatient",,,,"204","204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPIROMETRY","33050000","CDM","460","RC","94010","HCPCS",,,"facility","inpatient",,,,"653","653",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPIROMETRY","33050000","CDM","460","RC","94010","HCPCS",,,"facility","outpatient",,,,"653","653",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPIROMETRY PRE AND POST BRONCHODILATOR","33050001","CDM","460","RC","94060","HCPCS",,,"facility","inpatient",,,,"1449","1449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPIROMETRY PRE AND POST BRONCHODILATOR","33050001","CDM","460","RC","94060","HCPCS",,,"facility","outpatient",,,,"1449","1449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRONCHIAL PROVOCATION","33050002","CDM","460","RC","94070","HCPCS",,,"facility","inpatient",,,,"1709","1709",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRONCHIAL PROVOCATION","33050002","CDM","460","RC","94070","HCPCS",,,"facility","outpatient",,,,"1709","1709",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VITAL CAPACITY","33050003","CDM","460","RC","94150","HCPCS",,,"facility","inpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VITAL CAPACITY","33050003","CDM","460","RC","94150","HCPCS",,,"facility","outpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MAXIMAL VOLUNTARY VENTILATION","33050004","CDM","460","RC","94200","HCPCS",,,"facility","inpatient",,,,"312","312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MAXIMAL VOLUNTARY VENTILATION","33050004","CDM","460","RC","94200","HCPCS",,,"facility","outpatient",,,,"312","312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RESPIRATORY FLOW VOLUME LOOP","33050009","CDM","460","RC","94375","HCPCS",,,"facility","inpatient",,,,"750","750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RESPIRATORY FLOW VOLUME LOOP","33050009","CDM","460","RC","94375","HCPCS",,,"facility","outpatient",,,,"750","750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HYPOXIC RESPONSE CURVE","33050010","CDM","460","RC","94450","HCPCS",,,"facility","inpatient",,,,"3903","3903",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HYPOXIC RESPONSE CURVE","33050010","CDM","460","RC","94450","HCPCS",,,"facility","outpatient",,,,"3903","3903",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIGH ALTITUDE SIMULATION","33050011","CDM","460","RC","94452","HCPCS",,,"facility","inpatient",,,,"788","788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIGH ALTITUDE SIMULATION","33050011","CDM","460","RC","94452","HCPCS",,,"facility","outpatient",,,,"788","788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIGH ALTITUDE SIMULATION WITH O2 TITRATE","33050012","CDM","460","RC","94453","HCPCS",,,"facility","inpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIGH ALTITUDE SIMULATION WITH O2 TITRATE","33050012","CDM","460","RC","94453","HCPCS",,,"facility","outpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOPULM EXERCISE TESTING","33050014","CDM","460","RC","94621","HCPCS",,,"facility","inpatient",,,,"2115","2115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOPULM EXERCISE TESTING","33050014","CDM","460","RC","94621","HCPCS",,,"facility","outpatient",,,,"2115","2115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OXYGEN UPTAKE STUDY COMPLEX","33050016","CDM","460","RC","94681","HCPCS",,,"facility","inpatient",,,,"989","989",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OXYGEN UPTAKE STUDY COMPLEX","33050016","CDM","460","RC","94681","HCPCS",,,"facility","outpatient",,,,"989","989",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OXYGEN UPTAKE REST","33050017","CDM","460","RC","94690","HCPCS",,,"facility","inpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OXYGEN UPTAKE REST","33050017","CDM","460","RC","94690","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CO DIFFUSING CAPACITY","33050018","CDM","460","RC","94729","HCPCS",,,"facility","inpatient",,,,"775","775",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CO DIFFUSING CAPACITY","33050018","CDM","460","RC","94729","HCPCS",,,"facility","outpatient",,,,"775","775",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DX BRONCHOSCOPE/LAVAGE","33050031","CDM","361","RC","31624","HCPCS",,,"facility","inpatient",,,,"8295","8295",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DX BRONCHOSCOPE/LAVAGE","33050031","CDM","361","RC","31624","HCPCS",,,"facility","outpatient",,,,"8295","8295",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ARTERIAL PUNCTURE","33050033","CDM","410","RC","36600","HCPCS",,,"facility","inpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ARTERIAL PUNCTURE","33050033","CDM","410","RC","36600","HCPCS",,,"facility","outpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PULMONARY REHAB W EXER","33050035","CDM","940","RC","G0424","HCPCS",,,"facility","outpatient",,,,"473","473",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEROSOL TX INITIAL","33050036","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AEROSOL TX INITIAL","33050036","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPPB TX INITIAL","33050037","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPPB TX INITIAL","33050037","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPV INITIAL","33050038","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPV INITIAL","33050038","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MDI/NEB INITIAL","33050039","CDM","412","RC","94640","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MDI/NEB INITIAL","33050039","CDM","412","RC","94640","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHY/QHP OP PULM RHB W/O MNTR","33050044","CDM","940","RC","94625","HCPCS",,,"facility","inpatient",,,,"473","473",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHY/QHP OP PULM RHB W/O MNTR","33050044","CDM","940","RC","94625","HCPCS",,,"facility","outpatient",,,,"473","473",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXHALED NITRIC OXIDE MEAS","33050048","CDM","460","RC","95012","HCPCS",,,"facility","inpatient",,,,"340","340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXHALED NITRIC OXIDE MEAS","33050048","CDM","460","RC","95012","HCPCS",,,"facility","outpatient",,,,"340","340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRONCHOSCOPY CA NAVGATION","33050049","CDM","361","RC","31627","HCPCS",,,"facility","inpatient",,,,"8536","8536",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRONCHOSCOPY CA NAVGATION","33050049","CDM","361","RC","31627","HCPCS",,,"facility","outpatient",,,,"8536","8536",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHY/QHP OP PULM RHB W/MNTR","33050064","CDM","940","RC","94626","HCPCS",,,"facility","inpatient",,,,"473","473",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHY/QHP OP PULM RHB W/MNTR","33050064","CDM","940","RC","94626","HCPCS",,,"facility","outpatient",,,,"473","473",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SLEEP STUDY UNATTENDED","35000002","CDM","740","RC","95806","HCPCS",,,"facility","inpatient",,,,"875","875",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SLEEP STUDY UNATTENDED","35000002","CDM","740","RC","95806","HCPCS",,,"facility","outpatient",,,,"875","875",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG EXTEND MONITORING 41-60 MIN","35000006","CDM","740","RC","95812","HCPCS",,,"facility","inpatient",,,,"2466","2466",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG EXTEND MONITORING 41-60 MIN","35000006","CDM","740","RC","95812","HCPCS",,,"facility","outpatient",,,,"2466","2466",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG 61-119 MIN","35000007","CDM","740","RC","95813","HCPCS",,,"facility","inpatient",,,,"2482","2482",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG 61-119 MIN","35000007","CDM","740","RC","95813","HCPCS",,,"facility","outpatient",,,,"2482","2482",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG AWAKE AND DROWSY RECORDS 20-40 MIN","35000008","CDM","740","RC","95816","HCPCS",,,"facility","inpatient",,,,"2159","2159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG AWAKE AND DROWSY RECORDS 20-40 MIN","35000008","CDM","740","RC","95816","HCPCS",,,"facility","outpatient",,,,"2159","2159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG AWAKE AND ASLEEP RECORDS 20-40 MIN","35000009","CDM","740","RC","95819","HCPCS",,,"facility","inpatient",,,,"2327","2327",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG AWAKE AND ASLEEP RECORDS 20-40 MIN","35000009","CDM","740","RC","95819","HCPCS",,,"facility","outpatient",,,,"2327","2327",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG SLEEP COMA RECORDS 20-40 MIN","35000010","CDM","740","RC","95822","HCPCS",,,"facility","inpatient",,,,"2785","2785",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG SLEEP COMA RECORDS 20-40 MIN","35000010","CDM","740","RC","95822","HCPCS",,,"facility","outpatient",,,,"2785","2785",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG CEREBRAL DEATH EVALUATION","35000011","CDM","740","RC","95824","HCPCS",,,"facility","inpatient",,,,"2567","2567",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG CEREBRAL DEATH EVALUATION","35000011","CDM","740","RC","95824","HCPCS",,,"facility","outpatient",,,,"2567","2567",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELECTROCORTICOGRAM SURGERY","35000012","CDM","740","RC","95829","HCPCS",,,"facility","inpatient",,,,"2106","2106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELECTROCORTICOGRAM SURGERY","35000012","CDM","740","RC","95829","HCPCS",,,"facility","outpatient",,,,"2106","2106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPHENOID ELECTRODE INSERTION FOR EEG","35000013","CDM","920","RC","95830","HCPCS",,,"facility","inpatient",,,,"549","549",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPHENOID ELECTRODE INSERTION FOR EEG","35000013","CDM","920","RC","95830","HCPCS",,,"facility","outpatient",,,,"549","549",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TENSILON TEST FOR MYASTHENIA GRAVIS","35000014","CDM","920","RC","95857","HCPCS",,,"facility","inpatient",,,,"1059","1059",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TENSILON TEST FOR MYASTHENIA GRAVIS","35000014","CDM","920","RC","95857","HCPCS",,,"facility","outpatient",,,,"1059","1059",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG 1 EXTREMITY","35000015","CDM","922","RC","95860","HCPCS",,,"facility","inpatient",,,,"337","337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG 1 EXTREMITY","35000015","CDM","922","RC","95860","HCPCS",,,"facility","outpatient",,,,"337","337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG 2 EXTREMITIES","35000016","CDM","922","RC","95861","HCPCS",,,"facility","inpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG 2 EXTREMITIES","35000016","CDM","922","RC","95861","HCPCS",,,"facility","outpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG 3 EXTREMITIES","35000017","CDM","922","RC","95863","HCPCS",,,"facility","inpatient",,,,"1832","1832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG 3 EXTREMITIES","35000017","CDM","922","RC","95863","HCPCS",,,"facility","outpatient",,,,"1832","1832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG 4 EXTREMITIES","35000018","CDM","922","RC","95864","HCPCS",,,"facility","inpatient",,,,"470","470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG 4 EXTREMITIES","35000018","CDM","922","RC","95864","HCPCS",,,"facility","outpatient",,,,"470","470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG CRANIAL NERVE MUSCLE UNILATERAL","35000019","CDM","922","RC","95867","HCPCS",,,"facility","inpatient",,,,"4005","4005",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG CRANIAL NERVE MUSCLE UNILATERAL","35000019","CDM","922","RC","95867","HCPCS",,,"facility","outpatient",,,,"4005","4005",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG THORACIC PARASPINAL MUSCLE","35000021","CDM","922","RC","95869","HCPCS",,,"facility","inpatient",,,,"92","92",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG THORACIC PARASPINAL MUSCLE","35000021","CDM","922","RC","95869","HCPCS",,,"facility","outpatient",,,,"92","92",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG LIMITED STUDY","35000022","CDM","922","RC","95870","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG LIMITED STUDY","35000022","CDM","922","RC","95870","HCPCS",,,"facility","outpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEP UPPER LIMBS BILATERAL","35000029","CDM","920","RC","95925","HCPCS",,,"facility","inpatient",,,,"6853","6853",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEP UPPER LIMBS BILATERAL","35000029","CDM","920","RC","95925","HCPCS",,,"facility","outpatient",,,,"6853","6853",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG DURING SURGERY","35000035","CDM","740","RC","95955","HCPCS",,,"facility","inpatient",,,,"2404","2404",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG DURING SURGERY","35000035","CDM","740","RC","95955","HCPCS",,,"facility","outpatient",,,,"2404","2404",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WADA ACTIVATION TEST","35000037","CDM","740","RC","95958","HCPCS",,,"facility","inpatient",,,,"4247","4247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WADA ACTIVATION TEST","35000037","CDM","740","RC","95958","HCPCS",,,"facility","outpatient",,,,"4247","4247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FUNCTIONAL CORTICAL MAPPING EACH ADDITIONAL HOUR","35000038","CDM","740","RC","95962","HCPCS",,,"facility","inpatient",,,,"4245","4245",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FUNCTIONAL CORTICAL MAPPING EACH ADDITIONAL HOUR","35000038","CDM","740","RC","95962","HCPCS",,,"facility","outpatient",,,,"4245","4245",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEP LOWER LIMBS BILATERAL","35000039","CDM","920","RC","95926","HCPCS",,,"facility","inpatient",,,,"5486","5486",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEP LOWER LIMBS BILATERAL","35000039","CDM","920","RC","95926","HCPCS",,,"facility","outpatient",,,,"5486","5486",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VISUAL EP TEST CNS","35000040","CDM","920","RC","95930","HCPCS",,,"facility","inpatient",,,,"1169","1169",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VISUAL EP TEST CNS","35000040","CDM","920","RC","95930","HCPCS",,,"facility","outpatient",,,,"1169","1169",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROMUSCULAR JUNCTION TESTING EACH NERVE","35000041","CDM","922","RC","95937","HCPCS",,,"facility","inpatient",,,,"528","528",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROMUSCULAR JUNCTION TESTING EACH NERVE","35000041","CDM","922","RC","95937","HCPCS",,,"facility","outpatient",,,,"528","528",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REFILLING MAINTENANCE OF IMPLANTABLE PUMP SPINAL O","35000045","CDM","940","RC","95990","HCPCS",,,"facility","inpatient",,,,"857","857",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REFILLING MAINTENANCE OF IMPLANTABLE PUMP SPINAL O","35000045","CDM","940","RC","95990","HCPCS",,,"facility","outpatient",,,,"857","857",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEP LOWER LIMBS UNILATERAL","35000046","CDM","920","RC","95926","HCPCS",,,"facility","inpatient",,,"52","5486","5486",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG SEP LOWER LIMBS UNILATERAL","35000046","CDM","920","RC","95926","HCPCS",,,"facility","outpatient",,,"52","5486","5486",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services"
"HCHG MUSC TST DONE W/NERV TST LIM","35000049","CDM","922","RC","95885","HCPCS",,,"facility","inpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MUSC TST DONE W/NERV TST LIM","35000049","CDM","922","RC","95885","HCPCS",,,"facility","outpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MUSC TEST DONE W/N TEST COMP","35000050","CDM","922","RC","95886","HCPCS",,,"facility","inpatient",,,,"406","406",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MUSC TEST DONE W/N TEST COMP","35000050","CDM","922","RC","95886","HCPCS",,,"facility","outpatient",,,,"406","406",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MUSC TST DONE W/N TST NONEXT","35000051","CDM","922","RC","95887","HCPCS",,,"facility","inpatient",,,,"449","449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MUSC TST DONE W/N TST NONEXT","35000051","CDM","922","RC","95887","HCPCS",,,"facility","outpatient",,,,"449","449",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SOMATOSENSORY TESTING BI","35000052","CDM","920","RC","95938","HCPCS",,,"facility","inpatient",,,,"2432","2432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SOMATOSENSORY TESTING BI","35000052","CDM","920","RC","95938","HCPCS",,,"facility","outpatient",,,,"2432","2432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C MOTOR EVOKED UPR&LWR LIMBS","35000054","CDM","920","RC","95939","HCPCS",,,"facility","inpatient",,,,"2074","2074",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C MOTOR EVOKED UPR&LWR LIMBS","35000054","CDM","920","RC","95939","HCPCS",,,"facility","outpatient",,,,"2074","2074",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEP TRUNK/HEAD","35000055","CDM","920","RC","95927","HCPCS",,,"facility","inpatient",,,,"2961","2961",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEP TRUNK/HEAD","35000055","CDM","920","RC","95927","HCPCS",,,"facility","outpatient",,,,"2961","2961",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG ANAL/URETHRAL SPHNCTR","35000056","CDM","920","RC","51785","HCPCS",,,"facility","inpatient",,,,"1729","1729",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG ANAL/URETHRAL SPHNCTR","35000056","CDM","920","RC","51785","HCPCS",,,"facility","outpatient",,,,"1729","1729",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANS FCN SUDOMOTOR","35000058","CDM","920","RC","95923","HCPCS",,,"facility","inpatient",,,,"438","438",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANS FCN SUDOMOTOR","35000058","CDM","920","RC","95923","HCPCS",,,"facility","outpatient",,,,"438","438",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C MOTOR EVOKED UPPR LIMBS","35000059","CDM","920","RC","95928","HCPCS",,,"facility","inpatient",,,,"1171","1171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C MOTOR EVOKED UPPR LIMBS","35000059","CDM","920","RC","95928","HCPCS",,,"facility","outpatient",,,,"1171","1171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C MOTOR EVOKED, LWR LIMBS","35000060","CDM","920","RC","95929","HCPCS",,,"facility","inpatient",,,,"1636","1636",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C MOTOR EVOKED, LWR LIMBS","35000060","CDM","920","RC","95929","HCPCS",,,"facility","outpatient",,,,"1636","1636",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELCTRDE STIM BRAIN 1ST HR ( > 31 MIN)","35000061","CDM","740","RC","95961","HCPCS",,,"facility","inpatient",,,,"3362","3362",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELCTRDE STIM BRAIN 1ST HR ( > 31 MIN)","35000061","CDM","740","RC","95961","HCPCS",,,"facility","outpatient",,,,"3362","3362",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&/SENS 1-2 NRV CNDJ TST","35000065","CDM","922","RC","95907","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&/SENS 1-2 NRV CNDJ TST","35000065","CDM","922","RC","95907","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&/SENS 3-4 NRV CNDJ TST","35000066","CDM","922","RC","95908","HCPCS",,,"facility","inpatient",,,,"261","261",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&/SENS 3-4 NRV CNDJ TST","35000066","CDM","922","RC","95908","HCPCS",,,"facility","outpatient",,,,"261","261",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&/SENS 5-6 NRV CNDJ TST","35000067","CDM","922","RC","95909","HCPCS",,,"facility","inpatient",,,,"314","314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&/SENS 5-6 NRV CNDJ TST","35000067","CDM","922","RC","95909","HCPCS",,,"facility","outpatient",,,,"314","314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&SENS 7-8 NRV CNDJ TEST","35000068","CDM","922","RC","95910","HCPCS",,,"facility","inpatient",,,,"368","368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&SENS 7-8 NRV CNDJ TEST","35000068","CDM","922","RC","95910","HCPCS",,,"facility","outpatient",,,,"368","368",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&SEN 9-10 NRV CNDJ TEST","35000069","CDM","922","RC","95911","HCPCS",,,"facility","inpatient",,,,"421","421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&SEN 9-10 NRV CNDJ TEST","35000069","CDM","922","RC","95911","HCPCS",,,"facility","outpatient",,,,"421","421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&SEN 11-12 NRV CND TEST","35000070","CDM","922","RC","95912","HCPCS",,,"facility","inpatient",,,,"474","474",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&SEN 11-12 NRV CND TEST","35000070","CDM","922","RC","95912","HCPCS",,,"facility","outpatient",,,,"474","474",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&SENS 13/> NRV CND TEST","35000071","CDM","922","RC","95913","HCPCS",,,"facility","inpatient",,,,"527","527",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MOTOR&SENS 13/> NRV CND TEST","35000071","CDM","922","RC","95913","HCPCS",,,"facility","outpatient",,,,"527","527",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IONM IN OPERATNG ROOM EA 15 MIN","35000073","CDM","920","RC","95940","HCPCS",,,"facility","inpatient",,,,"1093","1093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IONM IN OPERATNG ROOM EA 15 MIN","35000073","CDM","920","RC","95940","HCPCS",,,"facility","outpatient",,,,"1093","1093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IONM REMOTE>1 PT OR PER HR","35000074","CDM","920","RC","95941","HCPCS",,,"facility","inpatient",,,,"7821","7821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IONM REMOTE>1 PT OR PER HR","35000074","CDM","920","RC","95941","HCPCS",,,"facility","outpatient",,,,"7821","7821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG W/O VID 2-12 HR UNMNTR","35000098","CDM","740","RC","95705","HCPCS",,,"facility","inpatient",,,,"3674","3674",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG W/O VID 2-12 HR UNMNTR","35000098","CDM","740","RC","95705","HCPCS",,,"facility","outpatient",,,,"3674","3674",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG WO VID 2-12HR INTMT MNTR","35000099","CDM","740","RC","95706","HCPCS",,,"facility","inpatient",,,,"4064","4064",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG WO VID 2-12HR INTMT MNTR","35000099","CDM","740","RC","95706","HCPCS",,,"facility","outpatient",,,,"4064","4064",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG W/O VID 2-12HR CONT MNTR","35000100","CDM","740","RC","95707","HCPCS",,,"facility","inpatient",,,,"1323","1323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG W/O VID 2-12HR CONT MNTR","35000100","CDM","740","RC","95707","HCPCS",,,"facility","outpatient",,,,"1323","1323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG WO VID EA 12-26HR UNMNTR","35000101","CDM","740","RC","95708","HCPCS",,,"facility","inpatient",,,,"3408","3408",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG WO VID EA 12-26HR UNMNTR","35000101","CDM","740","RC","95708","HCPCS",,,"facility","outpatient",,,,"3408","3408",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG W/O VID EA 12-26HR INTMT","35000102","CDM","740","RC","95709","HCPCS",,,"facility","inpatient",,,,"7774","7774",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG W/O VID EA 12-26HR INTMT","35000102","CDM","740","RC","95709","HCPCS",,,"facility","outpatient",,,,"7774","7774",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG W/O VID EA 12-26HR CONT","35000103","CDM","740","RC","95710","HCPCS",,,"facility","inpatient",,,,"6836","6836",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EEG W/O VID EA 12-26HR CONT","35000103","CDM","740","RC","95710","HCPCS",,,"facility","outpatient",,,,"6836","6836",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG 2-12 HR UNMONITORED","35000104","CDM","740","RC","95711","HCPCS",,,"facility","inpatient",,,,"1560","1560",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG 2-12 HR UNMONITORED","35000104","CDM","740","RC","95711","HCPCS",,,"facility","outpatient",,,,"1560","1560",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG 2-12 HR INTMT MNTR","35000105","CDM","740","RC","95712","HCPCS",,,"facility","inpatient",,,,"2463","2463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG 2-12 HR INTMT MNTR","35000105","CDM","740","RC","95712","HCPCS",,,"facility","outpatient",,,,"2463","2463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG 2-12 HR CONT MNTR","35000106","CDM","740","RC","95713","HCPCS",,,"facility","inpatient",,,,"3190","3190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG 2-12 HR CONT MNTR","35000106","CDM","740","RC","95713","HCPCS",,,"facility","outpatient",,,,"3190","3190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG EA 12-26 HR UNMNTR","35000107","CDM","740","RC","95714","HCPCS",,,"facility","inpatient",,,,"2971","2971",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG EA 12-26 HR UNMNTR","35000107","CDM","740","RC","95714","HCPCS",,,"facility","outpatient",,,,"2971","2971",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG EA 12-26HR INTMT MNTR","35000108","CDM","740","RC","95715","HCPCS",,,"facility","inpatient",,,,"4721","4721",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG EA 12-26HR INTMT MNTR","35000108","CDM","740","RC","95715","HCPCS",,,"facility","outpatient",,,,"4721","4721",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG EA 12-26HR CONT MNTR","35000109","CDM","740","RC","95716","HCPCS",,,"facility","inpatient",,,,"7418","7418",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VEEG EA 12-26HR CONT MNTR","35000109","CDM","740","RC","95716","HCPCS",,,"facility","outpatient",,,,"7418","7418",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LTM EEG SET-UP","35000110","CDM","740","RC","95700","HCPCS",,,"facility","inpatient",,,,"1182","1182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LTM EEG SET-UP","35000110","CDM","740","RC","95700","HCPCS",,,"facility","outpatient",,,,"1182","1182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LTM EEG SETUP-NON-TECH OR W/PT PLCD ELCTRDE","35000123","CDM","740","RC","95999","HCPCS",,,"facility","inpatient",,,,"798","798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LTM EEG SETUP-NON-TECH OR W/PT PLCD ELCTRDE","35000123","CDM","740","RC","95999","HCPCS",,,"facility","outpatient",,,,"798","798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CARD MRI VEL FLW MAP","39300000","CDM","610","RC","75565","HCPCS",,,"facility","inpatient",,,,"955","955",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MRI CARD MRI VEL FLW MAP","39300000","CDM","610","RC","75565","HCPCS",,,"facility","outpatient",,,,"955","955",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE UREA NITROGEN URINE TIMED","40900003","CDM","301","RC","84540","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE UREA NITROGEN URINE TIMED","40900003","CDM","301","RC","84540","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URIC ACID UR RAN","40900007","CDM","301","RC","84560","HCPCS",,,"facility","inpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URIC ACID UR RAN","40900007","CDM","301","RC","84560","HCPCS",,,"facility","outpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALLERGEN SPECIFIC IGE QN/SEMI CRUDE EXT","40900010","CDM","302","RC","86003","HCPCS",,,"facility","inpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALLERGEN SPECIFIC IGE QN/SEMI CRUDE EXT","40900010","CDM","302","RC","86003","HCPCS",,,"facility","outpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALPH 1 ANTITRYPSN","40900011","CDM","301","RC","82103","HCPCS",,,"facility","inpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALPH 1 ANTITRYPSN","40900011","CDM","301","RC","82103","HCPCS",,,"facility","outpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE APOLIPOPROTEIN B","40900012","CDM","301","RC","82172","HCPCS",,,"facility","inpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE APOLIPOPROTEIN B","40900012","CDM","301","RC","82172","HCPCS",,,"facility","outpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE APOLIPOPROTEIN A1","40900013","CDM","301","RC","82172","HCPCS",,,"facility","inpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE APOLIPOPROTEIN A1","40900013","CDM","301","RC","82172","HCPCS",,,"facility","outpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NATRIURETIC PEPTIDE","40900014","CDM","301","RC","83880","HCPCS",,,"facility","inpatient",,,,"601","601",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NATRIURETIC PEPTIDE","40900014","CDM","301","RC","83880","HCPCS",,,"facility","outpatient",,,,"601","601",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHOLESTEROL","40900015","CDM","301","RC","82465","HCPCS",,,"facility","inpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHOLESTEROL","40900015","CDM","301","RC","82465","HCPCS",,,"facility","outpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHENYTOIN FREE","40900017","CDM","301","RC","80186","HCPCS",,,"facility","inpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHENYTOIN FREE","40900017","CDM","301","RC","80186","HCPCS",,,"facility","outpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HDL CHOLESTEROL","40900018","CDM","301","RC","83718","HCPCS",,,"facility","inpatient",,,,"136","136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HDL CHOLESTEROL","40900018","CDM","301","RC","83718","HCPCS",,,"facility","outpatient",,,,"136","136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LDL DIRECT MSR","40900020","CDM","301","RC","83721","HCPCS",,,"facility","inpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LDL DIRECT MSR","40900020","CDM","301","RC","83721","HCPCS",,,"facility","outpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASSY TST BLD FCL","40900021","CDM","301","RC","82274","HCPCS",,,"facility","inpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASSY TST BLD FCL","40900021","CDM","301","RC","82274","HCPCS",,,"facility","outpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RUBEOLA AB IGG","40900022","CDM","302","RC","86765","HCPCS",,,"facility","inpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RUBEOLA AB IGG","40900022","CDM","302","RC","86765","HCPCS",,,"facility","outpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RUBEOLA AB IGM","40900023","CDM","302","RC","86765","HCPCS",,,"facility","inpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RUBEOLA AB IGM","40900023","CDM","302","RC","86765","HCPCS",,,"facility","outpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TB TST CELL IMM MS","40900024","CDM","302","RC","86480","HCPCS",,,"facility","inpatient",,,,"832","832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TB TST CELL IMM MS","40900024","CDM","302","RC","86480","HCPCS",,,"facility","outpatient",,,,"832","832",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRIGLYCERIDE","40900025","CDM","301","RC","84478","HCPCS",,,"facility","inpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRIGLYCERIDE","40900025","CDM","301","RC","84478","HCPCS",,,"facility","outpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTN ELECTRO UR","40900026","CDM","301","RC","84166","HCPCS",,,"facility","inpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTN ELECTRO UR","40900026","CDM","301","RC","84166","HCPCS",,,"facility","outpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VZV AB IGG","40900027","CDM","302","RC","86787","HCPCS",,,"facility","inpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VZV AB IGG","40900027","CDM","302","RC","86787","HCPCS",,,"facility","outpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VZV AB IGM","40900028","CDM","302","RC","86787","HCPCS",,,"facility","inpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VZV AB IGM","40900028","CDM","302","RC","86787","HCPCS",,,"facility","outpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPARIN ASSAY","40900031","CDM","305","RC","85520","HCPCS",,,"facility","inpatient",,,,"478","478",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPARIN ASSAY","40900031","CDM","305","RC","85520","HCPCS",,,"facility","outpatient",,,,"478","478",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR V","40900032","CDM","305","RC","85220","HCPCS",,,"facility","inpatient",,,,"334","334",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR V","40900032","CDM","305","RC","85220","HCPCS",,,"facility","outpatient",,,,"334","334",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR II","40900033","CDM","305","RC","85210","HCPCS",,,"facility","inpatient",,,,"302","302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR II","40900033","CDM","305","RC","85210","HCPCS",,,"facility","outpatient",,,,"302","302",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR IX","40900034","CDM","305","RC","85250","HCPCS",,,"facility","inpatient",,,,"394","394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR IX","40900034","CDM","305","RC","85250","HCPCS",,,"facility","outpatient",,,,"394","394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR VIII","40900035","CDM","305","RC","85240","HCPCS",,,"facility","inpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR VIII","40900035","CDM","305","RC","85240","HCPCS",,,"facility","outpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR VII","40900036","CDM","305","RC","85230","HCPCS",,,"facility","inpatient",,,,"394","394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR VII","40900036","CDM","305","RC","85230","HCPCS",,,"facility","outpatient",,,,"394","394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR X","40900037","CDM","305","RC","85260","HCPCS",,,"facility","inpatient",,,,"447","447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR X","40900037","CDM","305","RC","85260","HCPCS",,,"facility","outpatient",,,,"447","447",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR XI","40900038","CDM","305","RC","85270","HCPCS",,,"facility","inpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR XI","40900038","CDM","305","RC","85270","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR XII","40900039","CDM","305","RC","85280","HCPCS",,,"facility","inpatient",,,,"262","262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR XII","40900039","CDM","305","RC","85280","HCPCS",,,"facility","outpatient",,,,"262","262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV 1 RNA QN PCR W/WO REVRS TRNSCRP","40900040","CDM","306","RC","87536","HCPCS",,,"facility","inpatient",,,,"572","572",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV 1 RNA QN PCR W/WO REVRS TRNSCRP","40900040","CDM","306","RC","87536","HCPCS",,,"facility","outpatient",,,,"572","572",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN S ACTIVITY","40900041","CDM","305","RC","85306","HCPCS",,,"facility","inpatient",,,,"122","122",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN S ACTIVITY","40900041","CDM","305","RC","85306","HCPCS",,,"facility","outpatient",,,,"122","122",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VITAMIN D 25HYDROXY","40900042","CDM","301","RC","82306","HCPCS",,,"facility","inpatient",,,,"277","277",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VITAMIN D 25HYDROXY","40900042","CDM","301","RC","82306","HCPCS",,,"facility","outpatient",,,,"277","277",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PREALBUMIN","40900043","CDM","301","RC","84134","HCPCS",,,"facility","inpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PREALBUMIN","40900043","CDM","301","RC","84134","HCPCS",,,"facility","outpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN C ACTIVATED","40900044","CDM","305","RC","85307","HCPCS",,,"facility","inpatient",,,,"311","311",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN C ACTIVATED","40900044","CDM","305","RC","85307","HCPCS",,,"facility","outpatient",,,,"311","311",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CARDIOLIPIN IGA AB","40900045","CDM","302","RC","86147","HCPCS",,,"facility","inpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CARDIOLIPIN IGA AB","40900045","CDM","302","RC","86147","HCPCS",,,"facility","outpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CARDIOLIPIN IGG AB","40900046","CDM","302","RC","86147","HCPCS",,,"facility","inpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CARDIOLIPIN IGG AB","40900046","CDM","302","RC","86147","HCPCS",,,"facility","outpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CARDIOLIPIN IGM AB","40900047","CDM","302","RC","86147","HCPCS",,,"facility","inpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CARDIOLIPIN IGM AB","40900047","CDM","302","RC","86147","HCPCS",,,"facility","outpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C REACTIVE PROTEIN","40900048","CDM","302","RC","86140","HCPCS",,,"facility","inpatient",,,,"177","177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C REACTIVE PROTEIN","40900048","CDM","302","RC","86140","HCPCS",,,"facility","outpatient",,,,"177","177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE DHEA SULFATE","40900049","CDM","301","RC","82627","HCPCS",,,"facility","inpatient",,,,"124","124",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE DHEA SULFATE","40900049","CDM","301","RC","82627","HCPCS",,,"facility","outpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ERYTHROPOIETIN","40900050","CDM","301","RC","82668","HCPCS",,,"facility","inpatient",,,,"251","251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ERYTHROPOIETIN","40900050","CDM","301","RC","82668","HCPCS",,,"facility","outpatient",,,,"251","251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BETA HCG QUAN","40900051","CDM","301","RC","84702","HCPCS",,,"facility","inpatient",,,,"395","395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BETA HCG QUAN","40900051","CDM","301","RC","84702","HCPCS",,,"facility","outpatient",,,,"395","395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INSULIN","40900052","CDM","301","RC","83525","HCPCS",,,"facility","inpatient",,,,"210","210",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INSULIN","40900052","CDM","301","RC","83525","HCPCS",,,"facility","outpatient",,,,"210","210",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN C ACTIVITY","40900053","CDM","305","RC","85303","HCPCS",,,"facility","inpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN C ACTIVITY","40900053","CDM","305","RC","85303","HCPCS",,,"facility","outpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEP C VIRUS PCR QN W/WO REV TRNS","40900055","CDM","306","RC","87522","HCPCS",,,"facility","inpatient",,,,"432","432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEP C VIRUS PCR QN W/WO REV TRNS","40900055","CDM","306","RC","87522","HCPCS",,,"facility","outpatient",,,,"432","432",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C DIFF AMPLIFIED PROBE","40900056","CDM","306","RC","87493","HCPCS",,,"facility","inpatient",,,,"421","421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C DIFF AMPLIFIED PROBE","40900056","CDM","306","RC","87493","HCPCS",,,"facility","outpatient",,,,"421","421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CAMPY ID BY IMMUNOASSAY","40900058","CDM","306","RC","87899","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CAMPY ID BY IMMUNOASSAY","40900058","CDM","306","RC","87899","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT TYP FLUROSCENT","40900060","CDM","306","RC","87140","HCPCS",,,"facility","inpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT TYP FLUROSCENT","40900060","CDM","306","RC","87140","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MUMPS AB IGG","40900061","CDM","302","RC","86735","HCPCS",,,"facility","inpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MUMPS AB IGG","40900061","CDM","302","RC","86735","HCPCS",,,"facility","outpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TESTOSTERONE TOTAL","40900062","CDM","301","RC","84403","HCPCS",,,"facility","inpatient",,,,"141","141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TESTOSTERONE TOTAL","40900062","CDM","301","RC","84403","HCPCS",,,"facility","outpatient",,,,"141","141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SODIUM FLD","40900063","CDM","301","RC","84302","HCPCS",,,"facility","inpatient",,,,"42","42",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SODIUM FLD","40900063","CDM","301","RC","84302","HCPCS",,,"facility","outpatient",,,,"42","42",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE DRUG SCREEN CLASS LIST A","40900065","CDM","301","RC","80307","HCPCS",,,"facility","inpatient",,,,"781","781",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE DRUG SCREEN CLASS LIST A","40900065","CDM","301","RC","80307","HCPCS",,,"facility","outpatient",,,,"781","781",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CFTR GENE COMMON VARIANTS","40900067","CDM","301","RC","81220","HCPCS",,,"facility","inpatient",,,,"256","256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CFTR GENE COMMON VARIANTS","40900067","CDM","301","RC","81220","HCPCS",,,"facility","outpatient",,,,"256","256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGE","40900076","CDM","301","RC","82785","HCPCS",,,"facility","inpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGE","40900076","CDM","301","RC","82785","HCPCS",,,"facility","outpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SEX HORMONE BIND GLOB","40900077","CDM","301","RC","84270","HCPCS",,,"facility","inpatient",,,,"184","184",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SEX HORMONE BIND GLOB","40900077","CDM","301","RC","84270","HCPCS",,,"facility","outpatient",,,,"184","184",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE F2 GENE ANALYSIS 20210G>A","40900078","CDM","301","RC","81240","HCPCS",,,"facility","inpatient",,,,"201","201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE F2 GENE ANALYSIS 20210G>A","40900078","CDM","301","RC","81240","HCPCS",,,"facility","outpatient",,,,"201","201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE F5 GENE ANALYSIS LEIDEN","40900079","CDM","301","RC","81241","HCPCS",,,"facility","inpatient",,,,"301","301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE F5 GENE ANALYSIS LEIDEN","40900079","CDM","301","RC","81241","HCPCS",,,"facility","outpatient",,,,"301","301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MTHFR GENE","40900080","CDM","301","RC","81291","HCPCS",,,"facility","inpatient",,,,"477","477",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MTHFR GENE","40900080","CDM","301","RC","81291","HCPCS",,,"facility","outpatient",,,,"477","477",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RESP VIRUS 3-5 TARGETS","40900081","CDM","306","RC","87631","HCPCS",,,"facility","inpatient",,,,"465","465",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RESP VIRUS 3-5 TARGETS","40900081","CDM","306","RC","87631","HCPCS",,,"facility","outpatient",,,,"446","446",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RESP VIRUS 6-11 TARGETS","40900082","CDM","306","RC","87632","HCPCS",,,"facility","inpatient",,,,"920","920",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RESP VIRUS 6-11 TARGETS","40900082","CDM","306","RC","87632","HCPCS",,,"facility","outpatient",,,,"920","920",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RESP VIRUS 12-25 TARGETS","40900083","CDM","306","RC","87633","HCPCS",,,"facility","inpatient",,,,"1324","1324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RESP VIRUS 12-25 TARGETS","40900083","CDM","306","RC","87633","HCPCS",,,"facility","outpatient",,,,"1324","1324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLORIDE FLD","40900084","CDM","301","RC","82438","HCPCS",,,"facility","inpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLORIDE FLD","40900084","CDM","301","RC","82438","HCPCS",,,"facility","outpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AFB ISOLATE ID","40900085","CDM","306","RC","87118","HCPCS",,,"facility","inpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AFB ISOLATE ID","40900085","CDM","306","RC","87118","HCPCS",,,"facility","outpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TISSUE HOMOGENIZATION","40900086","CDM","306","RC","87176","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TISSUE HOMOGENIZATION","40900086","CDM","306","RC","87176","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT TYP AGGL","40900087","CDM","306","RC","87147","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT TYP AGGL","40900087","CDM","306","RC","87147","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALBUMIN OTHER SOURCE QN EA","40900088","CDM","301","RC","82042","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALBUMIN OTHER SOURCE QN EA","40900088","CDM","301","RC","82042","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE KETONES QUANTITATIVE","40900090","CDM","301","RC","82010","HCPCS",,,"facility","inpatient",,,,"245","245",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE KETONES QUANTITATIVE","40900090","CDM","301","RC","82010","HCPCS",,,"facility","outpatient",,,,"245","245",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OVA & PARASITES W CONC","40900094","CDM","306","RC","87177","HCPCS",,,"facility","inpatient",,,,"46","46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OVA & PARASITES W CONC","40900094","CDM","306","RC","87177","HCPCS",,,"facility","outpatient",,,,"46","46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT STL CAMPHYLOB EA PLT","40900095","CDM","306","RC","87046","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT STL CAMPHYLOB EA PLT","40900095","CDM","306","RC","87046","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BLOOD TYPE SEROLOGIC ANTGN DONOR EA","40900096","CDM","302","RC","86902","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BLOOD TYPE SEROLOGIC ANTGN DONOR EA","40900096","CDM","302","RC","86902","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RETICYTE/HGB CONCENTRATE","40900097","CDM","305","RC","85046","HCPCS",,,"facility","inpatient",,,,"51","51",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RETICYTE/HGB CONCENTRATE","40900097","CDM","305","RC","85046","HCPCS",,,"facility","outpatient",,,,"51","51",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR XA AB CHROMGN","40900099","CDM","305","RC","85130","HCPCS",,,"facility","inpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FCTR XA AB CHROMGN","40900099","CDM","305","RC","85130","HCPCS",,,"facility","outpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE B-P PERTUSSIS DNA QUL PCR","40900102","CDM","306","RC","87798","HCPCS",,,"facility","inpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE B-P PERTUSSIS DNA QUL PCR","40900102","CDM","306","RC","87798","HCPCS",,,"facility","outpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PSA TOTAL DIAGNOSTIC","40900103","CDM","301","RC","84153","HCPCS",,,"facility","inpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PSA TOTAL DIAGNOSTIC","40900103","CDM","301","RC","84153","HCPCS",,,"facility","outpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AFB CULT","40900104","CDM","306","RC","87116","HCPCS",,,"facility","inpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AFB CULT","40900104","CDM","306","RC","87116","HCPCS",,,"facility","outpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AFP TUMOR MARKER","40900105","CDM","301","RC","82105","HCPCS",,,"facility","inpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AFP TUMOR MARKER","40900105","CDM","301","RC","82105","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALBUMIN SERUM/PLASMA/BLD","40900106","CDM","301","RC","82040","HCPCS",,,"facility","inpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALBUMIN SERUM/PLASMA/BLD","40900106","CDM","301","RC","82040","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AST (SGOT)","40900107","CDM","301","RC","84450","HCPCS",,,"facility","inpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AST (SGOT)","40900107","CDM","301","RC","84450","HCPCS",,,"facility","outpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALT (SGPT)","40900108","CDM","301","RC","84460","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALT (SGPT)","40900108","CDM","301","RC","84460","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALK PHOSPHATASE","40900109","CDM","301","RC","84075","HCPCS",,,"facility","inpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALK PHOSPHATASE","40900109","CDM","301","RC","84075","HCPCS",,,"facility","outpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ANA (ANTI NUCLEAR AB)","40900110","CDM","302","RC","86038","HCPCS",,,"facility","inpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ANA (ANTI NUCLEAR AB)","40900110","CDM","302","RC","86038","HCPCS",,,"facility","outpatient",,,,"98","98",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ANA TTR","40900111","CDM","302","RC","86039","HCPCS",,,"facility","inpatient",,,,"218","218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ANA TTR","40900111","CDM","302","RC","86039","HCPCS",,,"facility","outpatient",,,,"218","218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASO SCRN","40900112","CDM","302","RC","86063","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASO SCRN","40900112","CDM","302","RC","86063","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AT3 ACTIVITY","40900113","CDM","305","RC","85300","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AT3 ACTIVITY","40900113","CDM","305","RC","85300","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MICROSOMAL AB","40900114","CDM","302","RC","86376","HCPCS",,,"facility","inpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MICROSOMAL AB","40900114","CDM","302","RC","86376","HCPCS",,,"facility","outpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VITAMIN B12","40900115","CDM","301","RC","82607","HCPCS",,,"facility","inpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VITAMIN B12","40900115","CDM","301","RC","82607","HCPCS",,,"facility","outpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BETA2 MICROGLOBULIN","40900116","CDM","301","RC","82232","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BETA2 MICROGLOBULIN","40900116","CDM","301","RC","82232","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BILIRUBIN DIRECT","40900117","CDM","301","RC","82248","HCPCS",,,"facility","inpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BILIRUBIN DIRECT","40900117","CDM","301","RC","82248","HCPCS",,,"facility","outpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BILIRUBIN TOTAL","40900118","CDM","301","RC","82247","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BILIRUBIN TOTAL","40900118","CDM","301","RC","82247","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BASIC METBLC PNL TOTAL CA","40900119","CDM","301","RC","80048","HCPCS",,,"facility","inpatient",,,,"383","383",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BASIC METBLC PNL TOTAL CA","40900119","CDM","301","RC","80048","HCPCS",,,"facility","outpatient",,,,"310","310",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE UREA NITROGEN QUANTITATIVE","40900120","CDM","301","RC","84520","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE UREA NITROGEN QUANTITATIVE","40900120","CDM","301","RC","84520","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COMPLEMENT C4","40900121","CDM","302","RC","86160","HCPCS",,,"facility","inpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COMPLEMENT C4","40900121","CDM","302","RC","86160","HCPCS",,,"facility","outpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COMPLEMENT C3","40900122","CDM","302","RC","86160","HCPCS",,,"facility","inpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COMPLEMENT C3","40900122","CDM","302","RC","86160","HCPCS",,,"facility","outpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CA 125","40900123","CDM","302","RC","86304","HCPCS",,,"facility","inpatient",,,,"273","273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CA 125","40900123","CDM","302","RC","86304","HCPCS",,,"facility","outpatient",,,,"273","273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CA 15 3 (27.29)","40900124","CDM","302","RC","86300","HCPCS",,,"facility","inpatient",,,,"192","192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CA 15 3 (27.29)","40900124","CDM","302","RC","86300","HCPCS",,,"facility","outpatient",,,,"192","192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CA 19 9","40900125","CDM","302","RC","86301","HCPCS",,,"facility","inpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CA 19 9","40900125","CDM","302","RC","86301","HCPCS",,,"facility","outpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CALCIUM","40900127","CDM","301","RC","82310","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CALCIUM","40900127","CDM","301","RC","82310","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CEA","40900128","CDM","301","RC","82378","HCPCS",,,"facility","inpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CEA","40900128","CDM","301","RC","82378","HCPCS",,,"facility","outpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CERULOPLASMIN","40900129","CDM","301","RC","82390","HCPCS",,,"facility","inpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CERULOPLASMIN","40900129","CDM","301","RC","82390","HCPCS",,,"facility","outpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLAMYDIA TRACH AMP PRB","40900130","CDM","306","RC","87491","HCPCS",,,"facility","inpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLAMYDIA TRACH AMP PRB","40900130","CDM","306","RC","87491","HCPCS",,,"facility","outpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GC AMP PRB","40900131","CDM","306","RC","87591","HCPCS",,,"facility","inpatient",,,,"285","285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GC AMP PRB","40900131","CDM","306","RC","87591","HCPCS",,,"facility","outpatient",,,,"285","285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COMPR MET PNL","40900133","CDM","301","RC","80053","HCPCS",,,"facility","inpatient",,,,"471","471",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COMPR MET PNL","40900133","CDM","301","RC","80053","HCPCS",,,"facility","outpatient",,,,"386","386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CENTROMERE AB","40900134","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CENTROMERE AB","40900134","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE","40900135","CDM","301","RC","82565","HCPCS",,,"facility","inpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE","40900135","CDM","301","RC","82565","HCPCS",,,"facility","outpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C REACTIVE PROTEIN HS","40900136","CDM","302","RC","86141","HCPCS",,,"facility","inpatient",,,,"227","227",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C REACTIVE PROTEIN HS","40900136","CDM","302","RC","86141","HCPCS",,,"facility","outpatient",,,,"227","227",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CYCLOSPORINE","40900137","CDM","301","RC","80158","HCPCS",,,"facility","inpatient",,,,"246","246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CYCLOSPORINE","40900137","CDM","301","RC","80158","HCPCS",,,"facility","outpatient",,,,"246","246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ANTI DNA DBL STRAND","40900141","CDM","302","RC","86225","HCPCS",,,"facility","inpatient",,,,"116","116",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ANTI DNA DBL STRAND","40900141","CDM","302","RC","86225","HCPCS",,,"facility","outpatient",,,,"116","116",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE EBV AB EARLY AG","40900143","CDM","302","RC","86663","HCPCS",,,"facility","inpatient",,,,"166","166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE EBV AB EARLY AG","40900143","CDM","302","RC","86663","HCPCS",,,"facility","outpatient",,,,"166","166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE EBV VCA AB IGG","40900144","CDM","302","RC","86665","HCPCS",,,"facility","inpatient",,,,"95","95",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE EBV VCA AB IGG","40900144","CDM","302","RC","86665","HCPCS",,,"facility","outpatient",,,,"95","95",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE EBV VCA AB IGM","40900145","CDM","302","RC","86665","HCPCS",,,"facility","inpatient",,,,"95","95",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE EBV VCA AB IGM","40900145","CDM","302","RC","86665","HCPCS",,,"facility","outpatient",,,,"95","95",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE EBV AB EBNA","40900146","CDM","302","RC","86664","HCPCS",,,"facility","inpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE EBV AB EBNA","40900146","CDM","302","RC","86664","HCPCS",,,"facility","outpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IRON","40900147","CDM","301","RC","83540","HCPCS",,,"facility","inpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IRON","40900147","CDM","301","RC","83540","HCPCS",,,"facility","outpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FERRITIN","40900148","CDM","301","RC","82728","HCPCS",,,"facility","inpatient",,,,"256","256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FERRITIN","40900148","CDM","301","RC","82728","HCPCS",,,"facility","outpatient",,,,"256","256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TACROLIMUS (FK506)","40900149","CDM","301","RC","80197","HCPCS",,,"facility","inpatient",,,,"152","152",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TACROLIMUS (FK506)","40900149","CDM","301","RC","80197","HCPCS",,,"facility","outpatient",,,,"152","152",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FOLATE","40900150","CDM","301","RC","82746","HCPCS",,,"facility","inpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FOLATE","40900150","CDM","301","RC","82746","HCPCS",,,"facility","outpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T3 FREE","40900151","CDM","301","RC","84481","HCPCS",,,"facility","inpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T3 FREE","40900151","CDM","301","RC","84481","HCPCS",,,"facility","outpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GIARDIA AG EIA","40900152","CDM","306","RC","87329","HCPCS",,,"facility","inpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GIARDIA AG EIA","40900152","CDM","306","RC","87329","HCPCS",,,"facility","outpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GGT","40900153","CDM","301","RC","82977","HCPCS",,,"facility","inpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GGT","40900153","CDM","301","RC","82977","HCPCS",,,"facility","outpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE","40900154","CDM","301","RC","82947","HCPCS",,,"facility","inpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE","40900154","CDM","301","RC","82947","HCPCS",,,"facility","outpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI STL EIA","40900155","CDM","306","RC","87338","HCPCS",,,"facility","inpatient",,,,"225","225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI STL EIA","40900155","CDM","306","RC","87338","HCPCS",,,"facility","outpatient",,,,"225","225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HAPTOGLOBIN QN","40900156","CDM","301","RC","83010","HCPCS",,,"facility","inpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HAPTOGLOBIN QN","40900156","CDM","301","RC","83010","HCPCS",,,"facility","outpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HOMOCYSTINE","40900157","CDM","301","RC","83090","HCPCS",,,"facility","inpatient",,,,"318","318",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HOMOCYSTINE","40900157","CDM","301","RC","83090","HCPCS",,,"facility","outpatient",,,,"318","318",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT HERPES","40900161","CDM","306","RC","87252","HCPCS",,,"facility","inpatient",,,,"225","225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT HERPES","40900161","CDM","306","RC","87252","HCPCS",,,"facility","outpatient",,,,"225","225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IMMUNOFIX SER","40900162","CDM","302","RC","86334","HCPCS",,,"facility","inpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IMMUNOFIX SER","40900162","CDM","302","RC","86334","HCPCS",,,"facility","outpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGG","40900163","CDM","301","RC","82784","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGG","40900163","CDM","301","RC","82784","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGF-1","40900164","CDM","301","RC","84305","HCPCS",,,"facility","inpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGF-1","40900164","CDM","301","RC","84305","HCPCS",,,"facility","outpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGFBP 3","40900165","CDM","301","RC","83519","HCPCS",,,"facility","inpatient",,,,"354","354",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGFBP 3","40900165","CDM","301","RC","83519","HCPCS",,,"facility","outpatient",,,,"354","354",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGA","40900166","CDM","301","RC","82784","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGA","40900166","CDM","301","RC","82784","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE JO 1 AB","40900168","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE JO 1 AB","40900168","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE POTASSIUM","40900169","CDM","301","RC","84132","HCPCS",,,"facility","inpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE POTASSIUM","40900169","CDM","301","RC","84132","HCPCS",,,"facility","outpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LDH","40900170","CDM","301","RC","83615","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LDH","40900170","CDM","301","RC","83615","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LIPID PNL","40900171","CDM","301","RC","80061","HCPCS",,,"facility","inpatient",,,,"343","343",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LIPID PNL","40900171","CDM","301","RC","80061","HCPCS",,,"facility","outpatient",,,,"343","343",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RUSSELL VIPER VENOM DILU","40900173","CDM","305","RC","85613","HCPCS",,,"facility","inpatient",,,,"68","68",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RUSSELL VIPER VENOM DILU","40900173","CDM","305","RC","85613","HCPCS",,,"facility","outpatient",,,,"68","68",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MAGNESIUM","40900174","CDM","301","RC","83735","HCPCS",,,"facility","inpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MAGNESIUM","40900174","CDM","301","RC","83735","HCPCS",,,"facility","outpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MR STAPH DNA AMP PROBE","40900175","CDM","306","RC","87641","HCPCS",,,"facility","inpatient",,,,"483","483",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MR STAPH DNA AMP PROBE","40900175","CDM","306","RC","87641","HCPCS",,,"facility","outpatient",,,,"483","483",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SODIUM","40900176","CDM","301","RC","84295","HCPCS",,,"facility","inpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SODIUM","40900176","CDM","301","RC","84295","HCPCS",,,"facility","outpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYPTOSPORIDIUM AG EIA","40900177","CDM","306","RC","87328","HCPCS",,,"facility","inpatient",,,,"124","124",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYPTOSPORIDIUM AG EIA","40900177","CDM","306","RC","87328","HCPCS",,,"facility","outpatient",,,,"124","124",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHOSPHORUS (PO4)","40900178","CDM","301","RC","84100","HCPCS",,,"facility","inpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHOSPHORUS (PO4)","40900178","CDM","301","RC","84100","HCPCS",,,"facility","outpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PSA FREE","40900179","CDM","301","RC","84154","HCPCS",,,"facility","inpatient",,,,"252","252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PSA FREE","40900179","CDM","301","RC","84154","HCPCS",,,"facility","outpatient",,,,"252","252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RHEUMATOID FCTR QN","40900180","CDM","302","RC","86431","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RHEUMATOID FCTR QN","40900180","CDM","302","RC","86431","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RENAL FUNCTION PNL","40900181","CDM","301","RC","80069","HCPCS",,,"facility","inpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RENAL FUNCTION PNL","40900181","CDM","301","RC","80069","HCPCS",,,"facility","outpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RPR NON-TREPNML AB QL","40900182","CDM","302","RC","86592","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RPR NON-TREPNML AB QL","40900182","CDM","302","RC","86592","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RPR TTR NON-TREPNML AB QN","40900183","CDM","302","RC","86593","HCPCS",,,"facility","inpatient",,,,"18","18",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RPR TTR NON-TREPNML AB QN","40900183","CDM","302","RC","86593","HCPCS",,,"facility","outpatient",,,,"18","18",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RUBELLA AB","40900184","CDM","302","RC","86762","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RUBELLA AB","40900184","CDM","302","RC","86762","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SCL 70 AB","40900185","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SCL 70 AB","40900185","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SICKLE CL SCRN","40900186","CDM","305","RC","85660","HCPCS",,,"facility","inpatient",,,,"46","46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SICKLE CL SCRN","40900186","CDM","305","RC","85660","HCPCS",,,"facility","outpatient",,,,"46","46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMITH AB","40900187","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMITH AB","40900187","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN ELECTRO SER","40900188","CDM","301","RC","84165","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN ELECTRO SER","40900188","CDM","301","RC","84165","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RO(SS A) AB","40900189","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RO(SS A) AB","40900189","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LA (SS B) AB","40900190","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LA (SS B) AB","40900190","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T3 TOTAL","40900191","CDM","301","RC","84480","HCPCS",,,"facility","inpatient",,,,"191","191",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T3 TOTAL","40900191","CDM","301","RC","84480","HCPCS",,,"facility","outpatient",,,,"191","191",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE THYROXINE (T4)","40900192","CDM","301","RC","84436","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE THYROXINE (T4)","40900192","CDM","301","RC","84436","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FREE T4","40900193","CDM","301","RC","84439","HCPCS",,,"facility","inpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FREE T4","40900193","CDM","301","RC","84439","HCPCS",,,"facility","outpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T LYMPH CD4 (HELPER) CNT","40900194","CDM","302","RC","86361","HCPCS",,,"facility","inpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T LYMPH CD4 (HELPER) CNT","40900194","CDM","302","RC","86361","HCPCS",,,"facility","outpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE THYROGLOBULIN AB","40900195","CDM","302","RC","86800","HCPCS",,,"facility","inpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE THYROGLOBULIN AB","40900195","CDM","302","RC","86800","HCPCS",,,"facility","outpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE THYROGLOBULIN","40900196","CDM","301","RC","84432","HCPCS",,,"facility","inpatient",,,,"166","166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE THYROGLOBULIN","40900196","CDM","301","RC","84432","HCPCS",,,"facility","outpatient",,,,"166","166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IRON BINDING CAPACITY","40900197","CDM","301","RC","83550","HCPCS",,,"facility","inpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IRON BINDING CAPACITY","40900197","CDM","301","RC","83550","HCPCS",,,"facility","outpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TOBRAMYCIN TR","40900198","CDM","301","RC","80200","HCPCS",,,"facility","inpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TOBRAMYCIN TR","40900198","CDM","301","RC","80200","HCPCS",,,"facility","outpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TOXOPLAS AB","40900201","CDM","302","RC","86777","HCPCS",,,"facility","inpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TOXOPLAS AB","40900201","CDM","302","RC","86777","HCPCS",,,"facility","outpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TOXOPLAS AB IGM","40900202","CDM","302","RC","86778","HCPCS",,,"facility","inpatient",,,,"287","287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TOXOPLAS AB IGM","40900202","CDM","302","RC","86778","HCPCS",,,"facility","outpatient",,,,"287","287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN TOTAL BLOOD","40900203","CDM","301","RC","84155","HCPCS",,,"facility","inpatient",,,,"56","56",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN TOTAL BLOOD","40900203","CDM","301","RC","84155","HCPCS",,,"facility","outpatient",,,,"56","56",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT TYP BY NA PRB DPT EA","40900204","CDM","306","RC","87149","HCPCS",,,"facility","inpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT TYP BY NA PRB DPT EA","40900204","CDM","306","RC","87149","HCPCS",,,"facility","outpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TSH","40900205","CDM","301","RC","84443","HCPCS",,,"facility","inpatient",,,,"313","313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TSH","40900205","CDM","301","RC","84443","HCPCS",,,"facility","outpatient",,,,"313","313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MICROALBUMIN UR RAN","40900206","CDM","301","RC","82043","HCPCS",,,"facility","inpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MICROALBUMIN UR RAN","40900206","CDM","301","RC","82043","HCPCS",,,"facility","outpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE UR RAN","40900207","CDM","301","RC","82570","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE UR RAN","40900207","CDM","301","RC","82570","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMYLASE UR RAN","40900208","CDM","301","RC","82150","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMYLASE UR RAN","40900208","CDM","301","RC","82150","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMYLASE","40900209","CDM","301","RC","82150","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMYLASE","40900209","CDM","301","RC","82150","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CALCIUM UR RAN","40900210","CDM","301","RC","82340","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CALCIUM UR RAN","40900210","CDM","301","RC","82340","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CALCIUM UR 24HR","40900211","CDM","301","RC","82340","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CALCIUM UR 24HR","40900211","CDM","301","RC","82340","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLORIDE URINE","40900212","CDM","301","RC","82436","HCPCS",,,"facility","inpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLORIDE URINE","40900212","CDM","301","RC","82436","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE UR 24HR","40900214","CDM","301","RC","82570","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE UR 24HR","40900214","CDM","301","RC","82570","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR FLUOR + OR ACID FAST","40900215","CDM","306","RC","87206","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR FLUOR + OR ACID FAST","40900215","CDM","306","RC","87206","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE UR RAN","40900216","CDM","301","RC","82945","HCPCS",,,"facility","inpatient",,,,"166","166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE UR RAN","40900216","CDM","301","RC","82945","HCPCS",,,"facility","outpatient",,,,"166","166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE UR 24HR","40900217","CDM","301","RC","82945","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE UR 24HR","40900217","CDM","301","RC","82945","HCPCS",,,"facility","outpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IMMUNOFIX UR","40900218","CDM","302","RC","86335","HCPCS",,,"facility","inpatient",,,,"308","308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IMMUNOFIX UR","40900218","CDM","302","RC","86335","HCPCS",,,"facility","outpatient",,,,"308","308",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE POTASSIUM UR RAN","40900219","CDM","301","RC","84133","HCPCS",,,"facility","inpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE POTASSIUM UR RAN","40900219","CDM","301","RC","84133","HCPCS",,,"facility","outpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE POTASSIUM UR 24 HR","40900220","CDM","301","RC","84133","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE POTASSIUM UR 24 HR","40900220","CDM","301","RC","84133","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MAGNESIUM UR TIM","40900221","CDM","301","RC","83735","HCPCS",,,"facility","inpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MAGNESIUM UR TIM","40900221","CDM","301","RC","83735","HCPCS",,,"facility","outpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA B DFA","40900222","CDM","306","RC","87275","HCPCS",,,"facility","inpatient",,,,"160","160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA B DFA","40900222","CDM","306","RC","87275","HCPCS",,,"facility","outpatient",,,,"160","160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA A DFA","40900223","CDM","306","RC","87276","HCPCS",,,"facility","inpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA A DFA","40900223","CDM","306","RC","87276","HCPCS",,,"facility","outpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MICROALBUMIN UR 24HR","40900224","CDM","301","RC","82043","HCPCS",,,"facility","inpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MICROALBUMIN UR 24HR","40900224","CDM","301","RC","82043","HCPCS",,,"facility","outpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CELL MARKER TECH ONLY 1ST","40900225","CDM","311","RC","88184","HCPCS",,,"facility","inpatient",,,,"285","285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CELL MARKER TECH ONLY 1ST","40900225","CDM","311","RC","88184","HCPCS",,,"facility","outpatient",,,,"285","285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MAGNESIUM UR RAN","40900226","CDM","301","RC","83735","HCPCS",,,"facility","inpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MAGNESIUM UR RAN","40900226","CDM","301","RC","83735","HCPCS",,,"facility","outpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SODIUM UR 24HR","40900227","CDM","301","RC","84300","HCPCS",,,"facility","inpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SODIUM UR 24HR","40900227","CDM","301","RC","84300","HCPCS",,,"facility","outpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHOSPHOROUS UR RAN","40900228","CDM","301","RC","84105","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHOSPHOROUS UR RAN","40900228","CDM","301","RC","84105","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHOSPHORUS UR TIM","40900229","CDM","301","RC","84105","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHOSPHORUS UR TIM","40900229","CDM","301","RC","84105","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PLT CNT AUTO","40900230","CDM","305","RC","85049","HCPCS",,,"facility","inpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PLT CNT AUTO","40900230","CDM","305","RC","85049","HCPCS",,,"facility","outpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PREGNANCY SCRN UR","40900231","CDM","307","RC","81025","HCPCS",,,"facility","inpatient",,,,"190","190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PREGNANCY SCRN UR","40900231","CDM","307","RC","81025","HCPCS",,,"facility","outpatient",,,,"190","190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PREGNANCY TEST SER QL","40900232","CDM","301","RC","84703","HCPCS",,,"facility","inpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PREGNANCY TEST SER QL","40900232","CDM","301","RC","84703","HCPCS",,,"facility","outpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROGESTERONE","40900233","CDM","301","RC","84144","HCPCS",,,"facility","inpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROGESTERONE","40900233","CDM","301","RC","84144","HCPCS",,,"facility","outpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROLACTIN","40900234","CDM","301","RC","84146","HCPCS",,,"facility","inpatient",,,,"262","262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROLACTIN","40900234","CDM","301","RC","84146","HCPCS",,,"facility","outpatient",,,,"262","262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CELL MARKER TECH EA ADDL","40900235","CDM","311","RC","88185","HCPCS",,,"facility","inpatient",,,,"31","31",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CELL MARKER TECH EA ADDL","40900235","CDM","311","RC","88185","HCPCS",,,"facility","outpatient",,,,"37","37",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE UREA NITROGEN URINE RANDOM","40900236","CDM","301","RC","84540","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE UREA NITROGEN URINE RANDOM","40900236","CDM","301","RC","84540","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PTH INTACT","40900237","CDM","301","RC","83970","HCPCS",,,"facility","inpatient",,,,"400","400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PTH INTACT","40900237","CDM","301","RC","83970","HCPCS",,,"facility","outpatient",,,,"400","400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PTT PLAS OR WB","40900238","CDM","305","RC","85730","HCPCS",,,"facility","inpatient",,,,"236","236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PTT PLAS OR WB","40900238","CDM","305","RC","85730","HCPCS",,,"facility","outpatient",,,,"236","236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RSV AG EIA","40900239","CDM","306","RC","87420","HCPCS",,,"facility","inpatient",,,,"357","357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RSV AG EIA","40900239","CDM","306","RC","87420","HCPCS",,,"facility","outpatient",,,,"357","357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MACROSCOPIC EXAM PARASITE","40900240","CDM","306","RC","87169","HCPCS",,,"facility","inpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MACROSCOPIC EXAM PARASITE","40900240","CDM","306","RC","87169","HCPCS",,,"facility","outpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SALICYLATE","40900241","CDM","301","RC","80179","HCPCS",,,"facility","inpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SALICYLATE","40900241","CDM","301","RC","80179","HCPCS",,,"facility","outpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR AFB STAIN","40900242","CDM","306","RC","87206","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR AFB STAIN","40900242","CDM","306","RC","87206","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR GRAM STAIN","40900243","CDM","306","RC","87205","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR GRAM STAIN","40900243","CDM","306","RC","87205","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR INCL BODIES PARASITE","40900244","CDM","306","RC","87207","HCPCS",,,"facility","inpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR INCL BODIES PARASITE","40900244","CDM","306","RC","87207","HCPCS",,,"facility","outpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SODIUM UR RAN","40900245","CDM","301","RC","84300","HCPCS",,,"facility","inpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SODIUM UR RAN","40900245","CDM","301","RC","84300","HCPCS",,,"facility","outpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE STL FOR WBC'S","40900246","CDM","306","RC","87205","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE STL FOR WBC'S","40900246","CDM","306","RC","87205","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE STREP GRP A AG EIA","40900247","CDM","306","RC","87430","HCPCS",,,"facility","inpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE STREP GRP A AG EIA","40900247","CDM","306","RC","87430","HCPCS",,,"facility","outpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CBC AUTO W AUTO DIFF WBC","40900249","CDM","305","RC","85025","HCPCS",,,"facility","inpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CBC AUTO W AUTO DIFF WBC","40900249","CDM","305","RC","85025","HCPCS",,,"facility","outpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRANSFERRIN","40900250","CDM","301","RC","84466","HCPCS",,,"facility","inpatient",,,,"198","198",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRANSFERRIN","40900250","CDM","301","RC","84466","HCPCS",,,"facility","outpatient",,,,"198","198",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URNALYSIS AUTO W/O MICRO","40900251","CDM","307","RC","81003","HCPCS",,,"facility","inpatient",,,,"102","102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URNALYSIS AUTO W/O MICRO","40900251","CDM","307","RC","81003","HCPCS",,,"facility","outpatient",,,,"102","102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VALPROIC ACID TOTAL","40900252","CDM","301","RC","80164","HCPCS",,,"facility","inpatient",,,,"406","406",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VALPROIC ACID TOTAL","40900252","CDM","301","RC","80164","HCPCS",,,"facility","outpatient",,,,"406","406",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VANCOMYCIN","40900253","CDM","301","RC","80202","HCPCS",,,"facility","inpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VANCOMYCIN","40900253","CDM","301","RC","80202","HCPCS",,,"facility","outpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ACETAMINOPHEN","40900256","CDM","301","RC","80143","HCPCS",,,"facility","inpatient",,,,"325","325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ACETAMINOPHEN","40900256","CDM","301","RC","80143","HCPCS",,,"facility","outpatient",,,,"325","325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALCOHOLS BLOOD","40900257","CDM","301","RC","82077","HCPCS",,,"facility","inpatient",,,,"271","271",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALCOHOLS BLOOD","40900257","CDM","301","RC","82077","HCPCS",,,"facility","outpatient",,,,"271","271",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR WET MOUNT","40900259","CDM","306","RC","87210","HCPCS",,,"facility","inpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR WET MOUNT","40900259","CDM","306","RC","87210","HCPCS",,,"facility","outpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTHROMBIN TIME","40900260","CDM","305","RC","85610","HCPCS",,,"facility","inpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTHROMBIN TIME","40900260","CDM","305","RC","85610","HCPCS",,,"facility","outpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URNALYSIS SGL ASSAY","40900261","CDM","307","RC","81002","HCPCS",,,"facility","inpatient",,,,"47","47",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URNALYSIS SGL ASSAY","40900261","CDM","307","RC","81002","HCPCS",,,"facility","outpatient",,,,"47","47",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VANCOMYCIN TR","40900263","CDM","301","RC","80202","HCPCS",,,"facility","inpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VANCOMYCIN TR","40900263","CDM","301","RC","80202","HCPCS",,,"facility","outpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ABO TYP SEROLOGIC","40900265","CDM","302","RC","86900","HCPCS",,,"facility","inpatient",,,,"205","205",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ABO TYP SEROLOGIC","40900265","CDM","302","RC","86900","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RH TYPE SEROLOGIC","40900266","CDM","302","RC","86901","HCPCS",,,"facility","inpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RH TYPE SEROLOGIC","40900266","CDM","302","RC","86901","HCPCS",,,"facility","outpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASSAY OF TROPONIN QUANT","40900267","CDM","301","RC","84484","HCPCS",,,"facility","inpatient",,,,"492","492",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASSAY OF TROPONIN QUANT","40900267","CDM","301","RC","84484","HCPCS",,,"facility","outpatient",,,,"492","492",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RETICULOCYTE AUTO","40900268","CDM","305","RC","85045","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RETICULOCYTE AUTO","40900268","CDM","305","RC","85045","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT UR COLONY CT ONLY","40900269","CDM","306","RC","87086","HCPCS",,,"facility","inpatient",,,,"237","237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT UR COLONY CT ONLY","40900269","CDM","306","RC","87086","HCPCS",,,"facility","outpatient",,,,"237","237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT VRE SCRN","40900270","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT VRE SCRN","40900270","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE D DIMER QN","40900271","CDM","305","RC","85379","HCPCS",,,"facility","inpatient",,,,"370","370",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE D DIMER QN","40900271","CDM","305","RC","85379","HCPCS",,,"facility","outpatient",,,,"370","370",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE DIGOXIN TOTAL","40900272","CDM","301","RC","80162","HCPCS",,,"facility","inpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE DIGOXIN TOTAL","40900272","CDM","301","RC","80162","HCPCS",,,"facility","outpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ELECTROLYTE PNL","40900273","CDM","301","RC","80051","HCPCS",,,"facility","inpatient",,,,"210","210",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ELECTROLYTE PNL","40900273","CDM","301","RC","80051","HCPCS",,,"facility","outpatient",,,,"210","210",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF TOTAL ESTRADIOL","40900274","CDM","301","RC","82670","HCPCS",,,"facility","inpatient",,,,"272","272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF TOTAL ESTRADIOL","40900274","CDM","301","RC","82670","HCPCS",,,"facility","outpatient",,,,"272","272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FIBRINOGEN","40900275","CDM","305","RC","85384","HCPCS",,,"facility","inpatient",,,,"320","320",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FIBRINOGEN","40900275","CDM","305","RC","85384","HCPCS",,,"facility","outpatient",,,,"320","320",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FSH","40900276","CDM","301","RC","83001","HCPCS",,,"facility","inpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FSH","40900276","CDM","301","RC","83001","HCPCS",,,"facility","outpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GENTAMICIN","40900277","CDM","301","RC","80170","HCPCS",,,"facility","inpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GENTAMICIN","40900277","CDM","301","RC","80170","HCPCS",,,"facility","outpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GIARDIA AB","40900278","CDM","302","RC","86674","HCPCS",,,"facility","inpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GIARDIA AB","40900278","CDM","302","RC","86674","HCPCS",,,"facility","outpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GROWTH HORMONE","40900279","CDM","301","RC","83003","HCPCS",,,"facility","inpatient",,,,"90","90",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GROWTH HORMONE","40900279","CDM","301","RC","83003","HCPCS",,,"facility","outpatient",,,,"90","90",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI AB TOTAL","40900280","CDM","302","RC","86677","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI AB TOTAL","40900280","CDM","302","RC","86677","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEMATOCRIT","40900281","CDM","305","RC","85014","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEMATOCRIT","40900281","CDM","305","RC","85014","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEMOGLOBIN","40900282","CDM","305","RC","85018","HCPCS",,,"facility","inpatient",,,,"73","73",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEMOGLOBIN","40900282","CDM","305","RC","85018","HCPCS",,,"facility","outpatient",,,,"73","73",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEMOGLOBIN GLYCOSYLTD A1C","40900283","CDM","301","RC","83036","HCPCS",,,"facility","inpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEMOGLOBIN GLYCOSYLTD A1C","40900283","CDM","301","RC","83036","HCPCS",,,"facility","outpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPATIC FUNCTION PNL","40900284","CDM","301","RC","80076","HCPCS",,,"facility","inpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPATIC FUNCTION PNL","40900284","CDM","301","RC","80076","HCPCS",,,"facility","outpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV 1/HIV 2 AB","40900285","CDM","302","RC","86703","HCPCS",,,"facility","inpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV 1/HIV 2 AB","40900285","CDM","302","RC","86703","HCPCS",,,"facility","outpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGM","40900286","CDM","301","RC","82784","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IGM","40900286","CDM","301","RC","82784","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA AG A OR B EACH","40900288","CDM","306","RC","87400","HCPCS",,,"facility","inpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA AG A OR B EACH","40900288","CDM","306","RC","87400","HCPCS",,,"facility","outpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LH","40900289","CDM","301","RC","83002","HCPCS",,,"facility","inpatient",,,,"327","327",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LH","40900289","CDM","301","RC","83002","HCPCS",,,"facility","outpatient",,,,"327","327",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LIPASE","40900290","CDM","301","RC","83690","HCPCS",,,"facility","inpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LIPASE","40900290","CDM","301","RC","83690","HCPCS",,,"facility","outpatient",,,,"257","257",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LITHIUM","40900291","CDM","301","RC","80178","HCPCS",,,"facility","inpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LITHIUM","40900291","CDM","301","RC","80178","HCPCS",,,"facility","outpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MONO TEST SCRN","40900292","CDM","302","RC","86308","HCPCS",,,"facility","inpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MONO TEST SCRN","40900292","CDM","302","RC","86308","HCPCS",,,"facility","outpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OCCLT BLD STL QL MULT SPC","40900294","CDM","301","RC","82270","HCPCS",,,"facility","inpatient",,,,"96","96",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OCCLT BLD STL QL MULT SPC","40900294","CDM","301","RC","82270","HCPCS",,,"facility","outpatient",,,,"96","96",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OSMOLALITY SER","40900295","CDM","301","RC","83930","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OSMOLALITY SER","40900295","CDM","301","RC","83930","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OSMOLALITY UR","40900296","CDM","301","RC","83935","HCPCS",,,"facility","inpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OSMOLALITY UR","40900296","CDM","301","RC","83935","HCPCS",,,"facility","outpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHENOBARBITAL","40900297","CDM","301","RC","80184","HCPCS",,,"facility","inpatient",,,,"314","314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHENOBARBITAL","40900297","CDM","301","RC","80184","HCPCS",,,"facility","outpatient",,,,"314","314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHENYTOIN TOTAL","40900298","CDM","301","RC","80185","HCPCS",,,"facility","inpatient",,,,"384","384",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PHENYTOIN TOTAL","40900298","CDM","301","RC","80185","HCPCS",,,"facility","outpatient",,,,"384","384",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PINWORM CELLOPHANE TAPE","40900299","CDM","306","RC","87172","HCPCS",,,"facility","inpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PINWORM CELLOPHANE TAPE","40900299","CDM","306","RC","87172","HCPCS",,,"facility","outpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ANTI RNP AB","40900300","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ANTI RNP AB","40900300","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TREPONEMA PALLIDUM","40900301","CDM","302","RC","86780","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TREPONEMA PALLIDUM","40900301","CDM","302","RC","86780","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN UR QN 24 HR","40900303","CDM","301","RC","84156","HCPCS",,,"facility","inpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN UR QN 24 HR","40900303","CDM","301","RC","84156","HCPCS",,,"facility","outpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN UR QN RAN","40900304","CDM","301","RC","84156","HCPCS",,,"facility","inpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN UR QN RAN","40900304","CDM","301","RC","84156","HCPCS",,,"facility","outpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URIC ACID","40900305","CDM","301","RC","84550","HCPCS",,,"facility","inpatient",,,,"125","125",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URIC ACID","40900305","CDM","301","RC","84550","HCPCS",,,"facility","outpatient",,,,"125","125",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AFB CULT BLD","40900308","CDM","306","RC","87116","HCPCS",,,"facility","inpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AFB CULT BLD","40900308","CDM","306","RC","87116","HCPCS",,,"facility","outpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALCOHOLS URINE","40900309","CDM","301","RC","80307","HCPCS",,,"facility","inpatient",,,,"781","781",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALCOHOLS URINE","40900309","CDM","301","RC","80307","HCPCS",,,"facility","outpatient",,,,"781","781",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMMONIA","40900310","CDM","301","RC","82140","HCPCS",,,"facility","inpatient",,,,"411","411",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMMONIA","40900310","CDM","301","RC","82140","HCPCS",,,"facility","outpatient",,,,"411","411",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BLD SMR EXAM W MAN DIFF","40900312","CDM","305","RC","85007","HCPCS",,,"facility","inpatient",,,,"97","97",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BLD SMR EXAM W MAN DIFF","40900312","CDM","305","RC","85007","HCPCS",,,"facility","outpatient",,,,"97","97",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CALCIUM IONIZED","40900313","CDM","301","RC","82330","HCPCS",,,"facility","inpatient",,,,"218","218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CALCIUM IONIZED","40900313","CDM","301","RC","82330","HCPCS",,,"facility","outpatient",,,,"218","218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CARBAMAZEPINE TOTAL","40900314","CDM","301","RC","80156","HCPCS",,,"facility","inpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CARBAMAZEPINE TOTAL","40900314","CDM","301","RC","80156","HCPCS",,,"facility","outpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CBC AUTO","40900315","CDM","305","RC","85027","HCPCS",,,"facility","inpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CBC AUTO","40900315","CDM","305","RC","85027","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CK TOTAL","40900316","CDM","301","RC","82550","HCPCS",,,"facility","inpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CK TOTAL","40900316","CDM","301","RC","82550","HCPCS",,,"facility","outpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COOMBS DIRECT POLY","40900318","CDM","302","RC","86880","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COOMBS DIRECT POLY","40900318","CDM","302","RC","86880","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CORTISOL (AM DRAW)","40900319","CDM","301","RC","82533","HCPCS",,,"facility","inpatient",,,,"283","283",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CORTISOL (AM DRAW)","40900319","CDM","301","RC","82533","HCPCS",,,"facility","outpatient",,,,"283","283",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CORTISOL (PM DRAW)","40900320","CDM","301","RC","82533","HCPCS",,,"facility","inpatient",,,,"283","283",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CORTISOL (PM DRAW)","40900320","CDM","301","RC","82533","HCPCS",,,"facility","outpatient",,,,"283","283",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CORTISOL TOTAL","40900321","CDM","301","RC","82533","HCPCS",,,"facility","inpatient",,,,"283","283",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CORTISOL TOTAL","40900321","CDM","301","RC","82533","HCPCS",,,"facility","outpatient",,,,"283","283",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ADENOVIRUS DFA","40900322","CDM","306","RC","87260","HCPCS",,,"facility","inpatient",,,,"184","184",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ADENOVIRUS DFA","40900322","CDM","306","RC","87260","HCPCS",,,"facility","outpatient",,,,"184","184",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BACT ANAEROBIC","40900324","CDM","306","RC","87075","HCPCS",,,"facility","inpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BACT ANAEROBIC","40900324","CDM","306","RC","87075","HCPCS",,,"facility","outpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BETA STREP A ONLY","40900325","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BETA STREP A ONLY","40900325","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BLD BACTERIA","40900326","CDM","306","RC","87040","HCPCS",,,"facility","inpatient",,,,"469","469",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BLD BACTERIA","40900326","CDM","306","RC","87040","HCPCS",,,"facility","outpatient",,,,"469","469",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNG SKIN HAIR NAIL","40900328","CDM","306","RC","87101","HCPCS",,,"facility","inpatient",,,,"63","63",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNG SKIN HAIR NAIL","40900328","CDM","306","RC","87101","HCPCS",,,"facility","outpatient",,,,"63","63",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT GC SCRN","40900329","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT GC SCRN","40900329","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT GRP B STREP SCRN","40900330","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT GRP B STREP SCRN","40900330","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT MRSA SCRN","40900331","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT MRSA SCRN","40900331","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT NASAL","40900332","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT NASAL","40900332","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT SCRN B PERTUSSUS","40900333","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT SCRN B PERTUSSUS","40900333","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT STL SALM & SHIG","40900334","CDM","306","RC","87045","HCPCS",,,"facility","inpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT STL SALM & SHIG","40900334","CDM","306","RC","87045","HCPCS",,,"facility","outpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYOGLOB QL OR SEMI QL","40900335","CDM","301","RC","82595","HCPCS",,,"facility","inpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYOGLOB QL OR SEMI QL","40900335","CDM","301","RC","82595","HCPCS",,,"facility","outpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMEAR COMPLEX STAIN OVA AND PARASITE","40900336","CDM","306","RC","87209","HCPCS",,,"facility","inpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMEAR COMPLEX STAIN OVA AND PARASITE","40900336","CDM","306","RC","87209","HCPCS",,,"facility","outpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV AMPLIFIED PROBE","40900339","CDM","306","RC","87529","HCPCS",,,"facility","inpatient",,,,"258","258",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV AMPLIFIED PROBE","40900339","CDM","306","RC","87529","HCPCS",,,"facility","outpatient",,,,"258","258",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN S FREE","40900341","CDM","305","RC","85306","HCPCS",,,"facility","inpatient",,,,"122","122",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN S FREE","40900341","CDM","305","RC","85306","HCPCS",,,"facility","outpatient",,,,"122","122",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE THROMBIN TIME","40900342","CDM","305","RC","85670","HCPCS",,,"facility","inpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE THROMBIN TIME","40900342","CDM","305","RC","85670","HCPCS",,,"facility","outpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GTT 1ST 3 SPEC INADDITION","40900345","CDM","301","RC","82951","HCPCS",,,"facility","inpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GTT 1ST 3 SPEC INADDITION","40900345","CDM","301","RC","82951","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI NON RAD BREATH","40900347","CDM","301","RC","83013","HCPCS",,,"facility","inpatient",,,,"354","354",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI NON RAD BREATH","40900347","CDM","301","RC","83013","HCPCS",,,"facility","outpatient",,,,"354","354",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PLT AGGREGATION EA AGENT","40900349","CDM","305","RC","85576","HCPCS",,,"facility","inpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PLT AGGREGATION EA AGENT","40900349","CDM","305","RC","85576","HCPCS",,,"facility","outpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HAV AB IGM","40900352","CDM","302","RC","86709","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HAV AB IGM","40900352","CDM","302","RC","86709","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUSCEPT BY ENZYME DETECT","40900354","CDM","306","RC","87185","HCPCS",,,"facility","inpatient",,,,"72","72",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUSCEPT BY ENZYME DETECT","40900354","CDM","306","RC","87185","HCPCS",,,"facility","outpatient",,,,"72","72",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URNALYSIS AUTO W/ MICRO","40900363","CDM","307","RC","81001","HCPCS",,,"facility","inpatient",,,,"141","141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE URNALYSIS AUTO W/ MICRO","40900363","CDM","307","RC","81001","HCPCS",,,"facility","outpatient",,,,"125","125",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AG DETECT EIA MULT STEP","40900364","CDM","306","RC","87449","HCPCS",,,"facility","inpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AG DETECT EIA MULT STEP","40900364","CDM","306","RC","87449","HCPCS",,,"facility","outpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HBS AG","40900365","CDM","306","RC","87340","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HBS AG","40900365","CDM","306","RC","87340","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PRENATAL PNL","40900366","CDM","301","RC","80055","HCPCS",,,"facility","inpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PRENATAL PNL","40900366","CDM","301","RC","80055","HCPCS",,,"facility","outpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE CLEARANCE","40900367","CDM","301","RC","82575","HCPCS",,,"facility","inpatient",,,,"239","239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE CLEARANCE","40900367","CDM","301","RC","82575","HCPCS",,,"facility","outpatient",,,,"239","239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR CRYPTOSPORIDIUM","40900368","CDM","306","RC","87206","HCPCS",,,"facility","inpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SMR CRYPTOSPORIDIUM","40900368","CDM","306","RC","87206","HCPCS",,,"facility","outpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HCV AB","40900369","CDM","302","RC","86803","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HCV AB","40900369","CDM","302","RC","86803","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HAV AB TOTAL","40900370","CDM","302","RC","86708","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HAV AB TOTAL","40900370","CDM","302","RC","86708","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HB CORE AB TOTAL","40900372","CDM","302","RC","86704","HCPCS",,,"facility","inpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HB CORE AB TOTAL","40900372","CDM","302","RC","86704","HCPCS",,,"facility","outpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HB CORE AB IGM","40900373","CDM","302","RC","86705","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HB CORE AB IGM","40900373","CDM","302","RC","86705","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HBS AB","40900374","CDM","302","RC","86706","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HBS AB","40900374","CDM","302","RC","86706","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT OTHER SOURCE AEROBIC","40900377","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT OTHER SOURCE AEROBIC","40900377","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLIADIN AB IGA","40900393","CDM","301","RC","83516","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLIADIN AB IGA","40900393","CDM","301","RC","83516","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FLUORESCENT AB SCRN EA AB","40900394","CDM","302","RC","86255","HCPCS",,,"facility","inpatient",,,,"197","197",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FLUORESCENT AB SCRN EA AB","40900394","CDM","302","RC","86255","HCPCS",,,"facility","outpatient",,,,"197","197",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLIADIN AB IGG","40900395","CDM","301","RC","83516","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLIADIN AB IGG","40900395","CDM","301","RC","83516","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRANSGLUTAMINASE AB IGG","40900396","CDM","301","RC","83516","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRANSGLUTAMINASE AB IGG","40900396","CDM","301","RC","83516","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRANSGLUTAMINASE AB IGA","40900397","CDM","301","RC","83516","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRANSGLUTAMINASE AB IGA","40900397","CDM","301","RC","83516","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT SCRN ONLY","40900401","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT SCRN ONLY","40900401","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE D DIMER SEMI QN/QL","40900404","CDM","305","RC","85378","HCPCS",,,"facility","inpatient",,,,"367","367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE D DIMER SEMI QN/QL","40900404","CDM","305","RC","85378","HCPCS",,,"facility","outpatient",,,,"367","367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SHIGA LIKE TOXIN EIA","40900409","CDM","306","RC","87427","HCPCS",,,"facility","inpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SHIGA LIKE TOXIN EIA","40900409","CDM","306","RC","87427","HCPCS",,,"facility","outpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUSCEPT BY E TEST","40900410","CDM","306","RC","87181","HCPCS",,,"facility","inpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUSCEPT BY E TEST","40900410","CDM","306","RC","87181","HCPCS",,,"facility","outpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FOLATE RBC","40900415","CDM","301","RC","82747","HCPCS",,,"facility","inpatient",,,,"69","69",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FOLATE RBC","40900415","CDM","301","RC","82747","HCPCS",,,"facility","outpatient",,,,"69","69",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB CAFFEINE","40900416","CDM","301","RC","80299","HCPCS",,,"facility","inpatient",,,,"260","260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB CAFFEINE","40900416","CDM","301","RC","80299","HCPCS",,,"facility","outpatient",,,,"260","260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB CRYOFIBRINOGEN","40900417","CDM","301","RC","82585","HCPCS",,,"facility","inpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB CRYOFIBRINOGEN","40900417","CDM","301","RC","82585","HCPCS",,,"facility","outpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB FAT STOOL QUALITATIVE","40900418","CDM","301","RC","82705","HCPCS",,,"facility","inpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB FAT STOOL QUALITATIVE","40900418","CDM","301","RC","82705","HCPCS",,,"facility","outpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB HEMOGLOBIN F (APT)","40900419","CDM","301","RC","83033","HCPCS",,,"facility","inpatient",,,,"216","216",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB HEMOGLOBIN F (APT)","40900419","CDM","301","RC","83033","HCPCS",,,"facility","outpatient",,,,"216","216",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB CLOTTING FACTOR XIII SCREEN SOLUBILITY","40900420","CDM","305","RC","85291","HCPCS",,,"facility","inpatient",,,,"355","355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB CLOTTING FACTOR XIII SCREEN SOLUBILITY","40900420","CDM","305","RC","85291","HCPCS",,,"facility","outpatient",,,,"355","355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB HEINZ BODIES DIRECT","40900421","CDM","305","RC","85441","HCPCS",,,"facility","inpatient",,,,"138","138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LAB HEINZ BODIES DIRECT","40900421","CDM","305","RC","85441","HCPCS",,,"facility","outpatient",,,,"138","138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEMOLYSIN ACID (HAM'S)","40900422","CDM","305","RC","85475","HCPCS",,,"facility","inpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEMOLYSIN ACID (HAM'S)","40900422","CDM","305","RC","85475","HCPCS",,,"facility","outpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPARIN NEUTRALIZATION","40900423","CDM","305","RC","85525","HCPCS",,,"facility","inpatient",,,,"23","23",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPARIN NEUTRALIZATION","40900423","CDM","305","RC","85525","HCPCS",,,"facility","outpatient",,,,"23","23",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LEUKOCYTE ALKALINE PHOSHATASE W COUNT","40900424","CDM","305","RC","85540","HCPCS",,,"facility","inpatient",,,,"14","14",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LEUKOCYTE ALKALINE PHOSHATASE W COUNT","40900424","CDM","305","RC","85540","HCPCS",,,"facility","outpatient",,,,"14","14",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV TYP 2 DFA","40900425","CDM","306","RC","87273","HCPCS",,,"facility","inpatient",,,,"57","57",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV TYP 2 DFA","40900425","CDM","306","RC","87273","HCPCS",,,"facility","outpatient",,,,"57","57",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV TYPE 1 DFA","40900426","CDM","306","RC","87274","HCPCS",,,"facility","inpatient",,,,"27","27",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV TYPE 1 DFA","40900426","CDM","306","RC","87274","HCPCS",,,"facility","outpatient",,,,"27","27",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LEGIONELLA PNEUMOPHILA DFA","40900427","CDM","306","RC","87278","HCPCS",,,"facility","inpatient",,,,"260","260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LEGIONELLA PNEUMOPHILA DFA","40900427","CDM","306","RC","87278","HCPCS",,,"facility","outpatient",,,,"260","260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PARAINFLUENZA AG BY DFA","40900428","CDM","306","RC","87279","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PARAINFLUENZA AG BY DFA","40900428","CDM","306","RC","87279","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VARICELLA ZOSTER DFA","40900429","CDM","306","RC","87290","HCPCS",,,"facility","inpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VARICELLA ZOSTER DFA","40900429","CDM","306","RC","87290","HCPCS",,,"facility","outpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFECT AGENT POLYVAL DFA","40900430","CDM","306","RC","87300","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFECT AGENT POLYVAL DFA","40900430","CDM","306","RC","87300","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MYCOBACTERIA TB AMPLIFIED PROBE","40900431","CDM","306","RC","87556","HCPCS",,,"facility","inpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MYCOBACTERIA TB AMPLIFIED PROBE","40900431","CDM","306","RC","87556","HCPCS",,,"facility","outpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE M AVIUM AMP PRB","40900432","CDM","306","RC","87561","HCPCS",,,"facility","inpatient",,,,"652","652",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE M AVIUM AMP PRB","40900432","CDM","306","RC","87561","HCPCS",,,"facility","outpatient",,,,"652","652",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT STL OTHER EA PLATE","40900433","CDM","306","RC","87046","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT STL OTHER EA PLATE","40900433","CDM","306","RC","87046","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUGARS QUALITATIVE EACH SPECIMEN","40900434","CDM","301","RC","84376","HCPCS",,,"facility","inpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUGARS QUALITATIVE EACH SPECIMEN","40900434","CDM","301","RC","84376","HCPCS",,,"facility","outpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AB SCRN","40900437","CDM","302","RC","86850","HCPCS",,,"facility","inpatient",,,,"255","255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AB SCRN","40900437","CDM","302","RC","86850","HCPCS",,,"facility","outpatient",,,,"255","255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT VIRAL","40900438","CDM","306","RC","87252","HCPCS",,,"facility","inpatient",,,,"225","225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT VIRAL","40900438","CDM","306","RC","87252","HCPCS",,,"facility","outpatient",,,,"225","225",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SIROLIMUS","40900441","CDM","301","RC","80195","HCPCS",,,"facility","inpatient",,,,"164","164",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SIROLIMUS","40900441","CDM","301","RC","80195","HCPCS",,,"facility","outpatient",,,,"164","164",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COOMBS INDIRECT EACH AB TITER","40900442","CDM","302","RC","86886","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COOMBS INDIRECT EACH AB TITER","40900442","CDM","302","RC","86886","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV 1 AB","40900445","CDM","302","RC","86701","HCPCS",,,"facility","inpatient",,,,"93","93",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV 1 AB","40900445","CDM","302","RC","86701","HCPCS",,,"facility","outpatient",,,,"93","93",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV 2 AB","40900446","CDM","302","RC","86702","HCPCS",,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV 2 AB","40900446","CDM","302","RC","86702","HCPCS",,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA DNA AMP PROB >2 TYPES","40900447","CDM","306","RC","87503","HCPCS",,,"facility","inpatient",,,,"83","83",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA DNA AMP PROB >2 TYPES","40900447","CDM","306","RC","87503","HCPCS",,,"facility","outpatient",,,,"83","83",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CLOTTING ASSAY WHOLE BLOOD","40900449","CDM","305","RC","85396","HCPCS",,,"facility","inpatient",,,,"463","463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CLOTTING ASSAY WHOLE BLOOD","40900449","CDM","305","RC","85396","HCPCS",,,"facility","outpatient",,,,"463","463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HPV LOW-RISK TYPES","40900464","CDM","306","RC","87623","HCPCS",,,"facility","inpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HPV LOW-RISK TYPES","40900464","CDM","306","RC","87623","HCPCS",,,"facility","outpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HPV HIGH-RISK TYPES W/ POOLED RESULTS","40900465","CDM","306","RC","87624","HCPCS",,,"facility","inpatient",,,,"577","577",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HPV HIGH-RISK TYPES W/ POOLED RESULTS","40900465","CDM","306","RC","87624","HCPCS",,,"facility","outpatient",,,,"577","577",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HPV TYPES 16 & 18 ONLY","40900466","CDM","306","RC","87625","HCPCS",,,"facility","inpatient",,,,"76","76",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HPV TYPES 16 & 18 ONLY","40900466","CDM","306","RC","87625","HCPCS",,,"facility","outpatient",,,,"76","76",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AG DETECT NOS DNA AMP","40900467","CDM","306","RC","87798","HCPCS",,,"facility","inpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AG DETECT NOS DNA AMP","40900467","CDM","306","RC","87798","HCPCS",,,"facility","outpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFECT AGENT ANTIGEN BY IMMUNOASSAY NOS","40900468","CDM","306","RC","87899","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFECT AGENT ANTIGEN BY IMMUNOASSAY NOS","40900468","CDM","306","RC","87899","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MYCOPLASMA AMPLIFIED NA PROBE","40900469","CDM","306","RC","87581","HCPCS",,,"facility","inpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MYCOPLASMA AMPLIFIED NA PROBE","40900469","CDM","306","RC","87581","HCPCS",,,"facility","outpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV-1 AG W/HIV-1/HIV-2 AB","40900470","CDM","306","RC","87389","HCPCS",,,"facility","inpatient",,,,"316","316",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV-1 AG W/HIV-1/HIV-2 AB","40900470","CDM","306","RC","87389","HCPCS",,,"facility","outpatient",,,,"316","316",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULTURE CRE SCREEN","40900471","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULTURE CRE SCREEN","40900471","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLAMYD PNEUMO AMP PRB","40900472","CDM","306","RC","87486","HCPCS",,,"facility","inpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLAMYD PNEUMO AMP PRB","40900472","CDM","306","RC","87486","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROCALCITONIN (PCT)","40900473","CDM","301","RC","84145","HCPCS",,,"facility","inpatient",,,,"625","625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROCALCITONIN (PCT)","40900473","CDM","301","RC","84145","HCPCS",,,"facility","outpatient",,,,"625","625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BETA 2 GLYCOPROTEIN I AB EA","40900474","CDM","302","RC","86146","HCPCS",,,"facility","inpatient",,,,"128","128",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BETA 2 GLYCOPROTEIN I AB EA","40900474","CDM","302","RC","86146","HCPCS",,,"facility","outpatient",,,,"128","128",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CMV AB IGG","40900475","CDM","302","RC","86644","HCPCS",,,"facility","inpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CMV AB IGG","40900475","CDM","302","RC","86644","HCPCS",,,"facility","outpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CMV AB IGM","40900476","CDM","302","RC","86645","HCPCS",,,"facility","inpatient",,,,"386","386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CMV AB IGM","40900476","CDM","302","RC","86645","HCPCS",,,"facility","outpatient",,,,"386","386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV 1 AB IGG TYPE SPECIFIC","40900477","CDM","302","RC","86695","HCPCS",,,"facility","inpatient",,,,"25","25",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV 1 AB IGG TYPE SPECIFIC","40900477","CDM","302","RC","86695","HCPCS",,,"facility","outpatient",,,,"25","25",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV 2 AB IGG TYPE SPECIFIC","40900478","CDM","302","RC","86696","HCPCS",,,"facility","inpatient",,,,"24","24",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HSV 2 AB IGG TYPE SPECIFIC","40900478","CDM","302","RC","86696","HCPCS",,,"facility","outpatient",,,,"24","24",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NOROVIRUS RNA PCR","40900479","CDM","306","RC","87798","HCPCS",,,"facility","inpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NOROVIRUS RNA PCR","40900479","CDM","306","RC","87798","HCPCS",,,"facility","outpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEP C SCREEN HIGH RISK/OTHER","40900480","CDM","302","RC","G0472","HCPCS",,,"facility","inpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEP C SCREEN HIGH RISK/OTHER","40900480","CDM","302","RC","G0472","HCPCS",,,"facility","outpatient",,,,"165","165",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PRENATAL OBSTETRIC PANEL W/HIV","40900481","CDM","301","RC","80081","HCPCS",,,"facility","inpatient",,,,"1009","1009",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PRENATAL OBSTETRIC PANEL W/HIV","40900481","CDM","301","RC","80081","HCPCS",,,"facility","outpatient",,,,"1009","1009",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LACTOFERRIN FECAL QUALITATIVE","40900482","CDM","301","RC","83630","HCPCS",,,"facility","inpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LACTOFERRIN FECAL QUALITATIVE","40900482","CDM","301","RC","83630","HCPCS",,,"facility","outpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT TYPE DNA/RNA AMPLIFIED PROBE EA","40900483","CDM","306","RC","87150","HCPCS",,,"facility","inpatient",,,,"268","268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT TYPE DNA/RNA AMPLIFIED PROBE EA","40900483","CDM","306","RC","87150","HCPCS",,,"facility","outpatient",,,,"268","268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MASS SPECT/TANDEM QN NES","40900484","CDM","301","RC","83789","HCPCS",,,"facility","inpatient",,,,"138","138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MASS SPECT/TANDEM QN NES","40900484","CDM","301","RC","83789","HCPCS",,,"facility","outpatient",,,,"138","138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN NEPHELOMETRY","40900486","CDM","301","RC","83883","HCPCS",,,"facility","inpatient",,,,"91","91",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN NEPHELOMETRY","40900486","CDM","301","RC","83883","HCPCS",,,"facility","outpatient",,,,"91","91",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CNS DNA AMP PROBE TYPE 12-25","40900491","CDM","306","RC","87483","HCPCS",,,"facility","inpatient",,,,"1424","1424",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CNS DNA AMP PROBE TYPE 12-25","40900491","CDM","306","RC","87483","HCPCS",,,"facility","outpatient",,,,"1424","1424",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA ENTEROVIRUS AMP PROBE W/WO RVRS TRNS","40900492","CDM","306","RC","87498","HCPCS",,,"facility","inpatient",,,,"403","403",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA ENTEROVIRUS AMP PROBE W/WO RVRS TRNS","40900492","CDM","306","RC","87498","HCPCS",,,"facility","outpatient",,,,"403","403",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SENSITIVITY MACROBROTH EA AGNT","40900493","CDM","306","RC","87188","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SENSITIVITY MACROBROTH EA AGNT","40900493","CDM","306","RC","87188","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE PRENATAL 50 GRAM SCREEN","40900495","CDM","301","RC","82950","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE PRENATAL 50 GRAM SCREEN","40900495","CDM","301","RC","82950","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TB AG RESPONSE T-CELL SUSP","40900497","CDM","302","RC","86481","HCPCS",,,"facility","inpatient",,,,"500","500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TB AG RESPONSE T-CELL SUSP","40900497","CDM","302","RC","86481","HCPCS",,,"facility","outpatient",,,,"500","500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPATITIS B VIRUS BDNA QUANTITATIVE","40900498","CDM","306","RC","87517","HCPCS",,,"facility","inpatient",,,,"388","388",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPATITIS B VIRUS BDNA QUANTITATIVE","40900498","CDM","306","RC","87517","HCPCS",,,"facility","outpatient",,,,"388","388",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RSV DNA/RNA AMP PROBE","40900499","CDM","306","RC","87634","HCPCS",,,"facility","inpatient",,,,"349","349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RSV DNA/RNA AMP PROBE","40900499","CDM","306","RC","87634","HCPCS",,,"facility","outpatient",,,,"349","349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE STREP A AMPLIF NA PROBE","40900500","CDM","306","RC","87651","HCPCS",,,"facility","inpatient",,,,"266","266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE STREP A AMPLIF NA PROBE","40900500","CDM","306","RC","87651","HCPCS",,,"facility","outpatient",,,,"266","266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRICHOMONAS VAGINALIS AMPLIFIED PROBE","40900501","CDM","306","RC","87661","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TRICHOMONAS VAGINALIS AMPLIFIED PROBE","40900501","CDM","306","RC","87661","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CANDIDA SPECIES AMPLIFIED PROBE","40900502","CDM","306","RC","87481","HCPCS",,,"facility","inpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CANDIDA SPECIES AMPLIFIED PROBE","40900502","CDM","306","RC","87481","HCPCS",,,"facility","outpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MULTIPLE ORGANISMS AMPLIFIED PROBE","40900503","CDM","306","RC","87801","HCPCS",,,"facility","inpatient",,,,"483","483",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE MULTIPLE ORGANISMS AMPLIFIED PROBE","40900503","CDM","306","RC","87801","HCPCS",,,"facility","outpatient",,,,"483","483",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALLERGEN SPEC IGE RECOMB EA","40900504","CDM","302","RC","86008","HCPCS",,,"facility","inpatient",,,,"57","57",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ALLERGEN SPEC IGE RECOMB EA","40900504","CDM","302","RC","86008","HCPCS",,,"facility","outpatient",,,,"57","57",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA SARS-COV-2 COVID-19 AMP PROBE TQ","40900505","CDM","306","RC","87635","HCPCS",,,"facility","inpatient",,,,"382","382",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA SARS-COV-2 COVID-19 AMP PROBE TQ","40900505","CDM","306","RC","87635","HCPCS",,,"facility","outpatient",,,,"382","382",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARS-COV-2 COVID-19 AMP PROB HI THRUPUT TQ","40900506","CDM","306","RC","U0003","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARS-COV-2 COVID-19 AMP PROB HI THRUPUT TQ","40900506","CDM","306","RC","U0003","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARS-COV-2 COVID-19 AB IGG","40900507","CDM","302","RC","86769","HCPCS",,,"facility","inpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARS-COV-2 COVID-19 AB IGG","40900507","CDM","302","RC","86769","HCPCS",,,"facility","outpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARS-COV-2 COVID-19 AB TOTAL","40900508","CDM","302","RC","86769","HCPCS",,,"facility","inpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARS-COV-2 COVID-19 AB TOTAL","40900508","CDM","302","RC","86769","HCPCS",,,"facility","outpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARSCOV2 COVID-19 & INF A&B AMP PRB","40900509","CDM","306","RC","87636","HCPCS",,,"facility","inpatient",,,,"532","532",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARSCOV2 COVID-19 & INF A&B AMP PRB","40900509","CDM","306","RC","87636","HCPCS",,,"facility","outpatient",,,,"532","532",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARSCOV2 COVID-19 & INF A&B&RSV AMP PRB","40900510","CDM","306","RC","87637","HCPCS",,,"facility","inpatient",,,,"605","605",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARSCOV2 COVID-19 & INF A&B&RSV AMP PRB","40900510","CDM","306","RC","87637","HCPCS",,,"facility","outpatient",,,,"605","605",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25","40900511","CDM","306","RC","87507","HCPCS",,,"facility","inpatient",,,,"1008","1008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25","40900511","CDM","306","RC","87507","HCPCS",,,"facility","outpatient",,,,"1008","1008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COV-19 AMP PRB HI THRUPUT W/IN 2 DAY COL","40900516","CDM","306","RC","U0005","HCPCS",,,"facility","inpatient",,,,"25","25",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COV-19 AMP PRB HI THRUPUT W/IN 2 DAY COL","40900516","CDM","306","RC","U0005","HCPCS",,,"facility","outpatient",,,,"25","25",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CUL TYP ID BLD PTHGN MULTIPLEX 6+ TRGT","40900520","CDM","306","RC","87154","HCPCS",,,"facility","inpatient",,,,"835","835",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CUL TYP ID BLD PTHGN MULTIPLEX 6+ TRGT","40900520","CDM","306","RC","87154","HCPCS",,,"facility","outpatient",,,,"835","835",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS","40900521","CDM","302","RC","86258","HCPCS",,,"facility","inpatient",,,,"69","69",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS","40900521","CDM","302","RC","86258","HCPCS",,,"facility","outpatient",,,,"69","69",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TISS TRNSGLUTMINSE EA IMMUNOGLOBULIN CLASS","40900522","CDM","302","RC","86364","HCPCS",,,"facility","inpatient",,,,"68","68",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TISS TRNSGLUTMINSE EA IMMUNOGLOBULIN CLASS","40900522","CDM","302","RC","86364","HCPCS",,,"facility","outpatient",,,,"68","68",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARS-COV-2 COVID19 ANTIGEN W/OPTICAL OBS","40900523","CDM","306","RC","87811","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SARS-COV-2 COVID19 ANTIGEN W/OPTICAL OBS","40900523","CDM","306","RC","87811","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ENDOMYSIAL ANTIBODY EA IMMUNOGLOBULIN CLAS","40900524","CDM","302","RC","86231","HCPCS",,,"facility","inpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ENDOMYSIAL ANTIBODY EA IMMUNOGLOBULIN CLAS","40900524","CDM","302","RC","86231","HCPCS",,,"facility","outpatient",,,,"26","26",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IMMUNOGLOBULIN LIGHT CHAINS FREE EACH","40900525","CDM","301","RC","83521","HCPCS",,,"facility","inpatient",,,,"102","102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IMMUNOGLOBULIN LIGHT CHAINS FREE EACH","40900525","CDM","301","RC","83521","HCPCS",,,"facility","outpatient",,,,"102","102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA NOS QUANTIFICATION EACH ORGANISM","40900526","CDM","306","RC","87799","HCPCS",,,"facility","inpatient",,,,"363","363",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA NOS QUANTIFICATION EACH ORGANISM","40900526","CDM","306","RC","87799","HCPCS",,,"facility","outpatient",,,,"363","363",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA CYTOMEGALOVIRUS QUANTIFICATION","40900527","CDM","306","RC","87497","HCPCS",,,"facility","inpatient",,,,"380","380",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA CYTOMEGALOVIRUS QUANTIFICATION","40900527","CDM","306","RC","87497","HCPCS",,,"facility","outpatient",,,,"380","380",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPB SCREEN NON-PREGNANT HIGH RISK INDIV","40900528","CDM","306","RC","G0499","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPB SCREEN NON-PREGNANT HIGH RISK INDIV","40900528","CDM","306","RC","G0499","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI DRUG ADMINISTRATION","40900529","CDM","301","RC","83014","HCPCS",,,"facility","inpatient",,,,"63","63",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI DRUG ADMINISTRATION","40900529","CDM","301","RC","83014","HCPCS",,,"facility","outpatient",,,,"63","63",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA ORTHOPOXVIRUS AMP PRB TECHNIQUE EA","40900534","CDM","306","RC","87593","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IADNA ORTHOPOXVIRUS AMP PRB TECHNIQUE EA","40900534","CDM","306","RC","87593","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NFCT DS BCT/VIR R DNA/RNA 22 TRGT SARSCOV2","40900535","CDM","309","RC","0202U","HCPCS",,,"facility","inpatient",,,,"1553","1553",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NFCT DS BCT/VIR R DNA/RNA 22 TRGT SARSCOV2","40900535","CDM","309","RC","0202U","HCPCS",,,"facility","outpatient",,,,"1523","1523",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COCCIDIOIDES AB","40900548","CDM","302","RC","86635","HCPCS",,,"facility","inpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE COCCIDIOIDES AB","40900548","CDM","302","RC","86635","HCPCS",,,"facility","outpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IA INFECTIONS AGT AB QUANT","40900551","CDM","302","RC","86317","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IA INFECTIONS AGT AB QUANT","40900551","CDM","302","RC","86317","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NFCT DS BV&VAGINITIS DNA ALG","40900552","CDM","309","RC","81515","HCPCS",,,"facility","inpatient",,,,"581","581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NFCT DS BV&VAGINITIS DNA ALG","40900552","CDM","309","RC","81515","HCPCS",,,"facility","outpatient",,,,"581","581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HPV SEP HI-RSK TYP&POOL RSLT","40900553","CDM","306","RC","87626","HCPCS",,,"facility","inpatient",,,,"609","609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HPV SEP HI-RSK TYP&POOL RSLT","40900553","CDM","306","RC","87626","HCPCS",,,"facility","outpatient",,,,"609","609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NFCT DS BV RNA VAG FLU ALG","40900554","CDM","309","RC","81513","HCPCS",,,"facility","inpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE NFCT DS BV RNA VAG FLU ALG","40900554","CDM","309","RC","81513","HCPCS",,,"facility","outpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LRT IAD 18BCT/8VIR&7ARG RNA","40900555","CDM","309","RC","0528U","HCPCS",,,"facility","inpatient",,,,"1868","1868",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LRT IAD 18BCT/8VIR&7ARG RNA","40900555","CDM","309","RC","0528U","HCPCS",,,"facility","outpatient",,,,"1831","1831",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV AG W/HIV1&2 ANTB W/OPTIC","40900556","CDM","306","RC","87806","HCPCS",,,"facility","inpatient",,,,"325","325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HIV AG W/HIV1&2 ANTB W/OPTIC","40900556","CDM","306","RC","87806","HCPCS",,,"facility","outpatient",,,,"325","325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLMY TRCH&NEISRA GONOR MULT","40900557","CDM","306","RC","87494","HCPCS",,,"facility","inpatient",,,,"595","595",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CHLMY TRCH&NEISRA GONOR MULT","40900557","CDM","306","RC","87494","HCPCS",,,"facility","outpatient",,,,"595","595",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULTURE CATHETER TIP","40950005","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULTURE CATHETER TIP","40950005","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULTURE EAR","40950006","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULTURE EAR","40950006","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULTURE EYE","40950007","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULTURE EYE","40950007","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE FLD","40950010","CDM","301","RC","82570","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CREATININE FLD","40950010","CDM","301","RC","82570","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LACTIC ACID","40950011","CDM","301","RC","83605","HCPCS",,,"facility","inpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE LACTIC ACID","40950011","CDM","301","RC","83605","HCPCS",,,"facility","outpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AB ID","40950013","CDM","302","RC","86870","HCPCS",,,"facility","inpatient",,,,"669","669",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AB ID","40950013","CDM","302","RC","86870","HCPCS",,,"facility","outpatient",,,,"669","669",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BACT AEROBIC ID","40950014","CDM","306","RC","87077","HCPCS",,,"facility","inpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BACT AEROBIC ID","40950014","CDM","306","RC","87077","HCPCS",,,"facility","outpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUSCEPT MIC PER PLATE","40950016","CDM","306","RC","87186","HCPCS",,,"facility","inpatient",,,,"301","301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUSCEPT MIC PER PLATE","40950016","CDM","306","RC","87186","HCPCS",,,"facility","outpatient",,,,"301","301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C DIFFICILE TOXIN EIA","40950019","CDM","306","RC","87324","HCPCS",,,"facility","inpatient",,,,"194","194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C DIFFICILE TOXIN EIA","40950019","CDM","306","RC","87324","HCPCS",,,"facility","outpatient",,,,"194","194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SEDIMENTATION RATE AUTO","40950020","CDM","305","RC","85652","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SEDIMENTATION RATE AUTO","40950020","CDM","305","RC","85652","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T3 UPTAKE","40950021","CDM","301","RC","84479","HCPCS",,,"facility","inpatient",,,,"84","84",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T3 UPTAKE","40950021","CDM","301","RC","84479","HCPCS",,,"facility","outpatient",,,,"84","84",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BACT ANAEROBIC ID","40950022","CDM","306","RC","87076","HCPCS",,,"facility","inpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT BACT ANAEROBIC ID","40950022","CDM","306","RC","87076","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNGUS YEAST ID","40950023","CDM","306","RC","87106","HCPCS",,,"facility","inpatient",,,,"222","222",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNGUS YEAST ID","40950023","CDM","306","RC","87106","HCPCS",,,"facility","outpatient",,,,"222","222",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IMMUNOASSAY NONINFECT","40950025","CDM","301","RC","83516","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE IMMUNOASSAY NONINFECT","40950025","CDM","301","RC","83516","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN TOTAL CSF","40950026","CDM","301","RC","84157","HCPCS",,,"facility","inpatient",,,,"233","233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN TOTAL CSF","40950026","CDM","301","RC","84157","HCPCS",,,"facility","outpatient",,,,"233","233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE FLD","40950027","CDM","301","RC","82945","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE FLD","40950027","CDM","301","RC","82945","HCPCS",,,"facility","outpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN TOTAL FLD","40950028","CDM","301","RC","84157","HCPCS",,,"facility","inpatient",,,,"233","233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PROTEIN TOTAL FLD","40950028","CDM","301","RC","84157","HCPCS",,,"facility","outpatient",,,,"233","233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE KOH PREP SKIN HAIR NAIL","40950029","CDM","306","RC","87220","HCPCS",,,"facility","inpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE KOH PREP SKIN HAIR NAIL","40950029","CDM","306","RC","87220","HCPCS",,,"facility","outpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CELL CNT FLD W/ DIFF","40950030","CDM","309","RC","89051","HCPCS",,,"facility","inpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CELL CNT FLD W/ DIFF","40950030","CDM","309","RC","89051","HCPCS",,,"facility","outpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE CSF","40950031","CDM","301","RC","82945","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE CSF","40950031","CDM","301","RC","82945","HCPCS",,,"facility","outpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE KETONES QL","40950033","CDM","301","RC","82009","HCPCS",,,"facility","inpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE KETONES QL","40950033","CDM","301","RC","82009","HCPCS",,,"facility","outpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYSTAL ID TISS/FLD NO UR","40950034","CDM","309","RC","89060","HCPCS",,,"facility","inpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYSTAL ID TISS/FLD NO UR","40950034","CDM","309","RC","89060","HCPCS",,,"facility","outpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FETAL FIBRONECTIN","40950035","CDM","301","RC","82731","HCPCS",,,"facility","inpatient",,,,"1161","1161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FETAL FIBRONECTIN","40950035","CDM","301","RC","82731","HCPCS",,,"facility","outpatient",,,,"1161","1161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BODY FLUID PH NOS","40950036","CDM","301","RC","83986","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE BODY FLUID PH NOS","40950036","CDM","301","RC","83986","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE UREA CLEARANCE","40950038","CDM","301","RC","84545","HCPCS",,,"facility","inpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE UREA CLEARANCE","40950038","CDM","301","RC","84545","HCPCS",,,"facility","outpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C-PEPTIDE","40950039","CDM","301","RC","84681","HCPCS",,,"facility","inpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE C-PEPTIDE","40950039","CDM","301","RC","84681","HCPCS",,,"facility","outpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ROTAVIRUS AG EIA","40950040","CDM","306","RC","87425","HCPCS",,,"facility","inpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ROTAVIRUS AG EIA","40950040","CDM","306","RC","87425","HCPCS",,,"facility","outpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OCCULT BLD IA SCRN","40950055","CDM","301","RC","G0328","HCPCS",,,"facility","inpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE OCCULT BLD IA SCRN","40950055","CDM","301","RC","G0328","HCPCS",,,"facility","outpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT STL E COLI EA PLATE","40950057","CDM","306","RC","87046","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT STL E COLI EA PLATE","40950057","CDM","306","RC","87046","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GENERAL HEALTH PNL","40950058","CDM","301","RC","80050","HCPCS",,,"facility","inpatient",,,"GY","583","583",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG CORE GENERAL HEALTH PNL","40950058","CDM","301","RC","80050","HCPCS",,,"facility","outpatient",,,"GY","583","583",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG CORE AT3 AG IMMUNOLOGIC","40950059","CDM","305","RC","85301","HCPCS",,,"facility","inpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AT3 AG IMMUNOLOGIC","40950059","CDM","305","RC","85301","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASO TTR","40950060","CDM","302","RC","86060","HCPCS",,,"facility","inpatient",,,,"50","50",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASO TTR","40950060","CDM","302","RC","86060","HCPCS",,,"facility","outpatient",,,,"50","50",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T LMPH TOT CNT","40950061","CDM","302","RC","86359","HCPCS",,,"facility","inpatient",,,,"192","192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T LMPH TOT CNT","40950061","CDM","302","RC","86359","HCPCS",,,"facility","outpatient",,,,"192","192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI AB IGG","40950062","CDM","302","RC","86677","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE H PYLORI AB IGG","40950062","CDM","302","RC","86677","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HBS AG NEUTRALIZATION","40950063","CDM","306","RC","87341","HCPCS",,,"facility","inpatient",,,,"43","43",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HBS AG NEUTRALIZATION","40950063","CDM","306","RC","87341","HCPCS",,,"facility","outpatient",,,,"43","43",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RSV RNA QUAL PCR","40950070","CDM","306","RC","87798","HCPCS",,,"facility","inpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE RSV RNA QUAL PCR","40950070","CDM","306","RC","87798","HCPCS",,,"facility","outpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FETAL RBC SMR (K B)","40950074","CDM","305","RC","85460","HCPCS",,,"facility","inpatient",,,,"181","181",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FETAL RBC SMR (K B)","40950074","CDM","305","RC","85460","HCPCS",,,"facility","outpatient",,,,"181","181",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VISCOSITY","40950075","CDM","305","RC","85810","HCPCS",,,"facility","inpatient",,,,"193","193",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VISCOSITY","40950075","CDM","305","RC","85810","HCPCS",,,"facility","outpatient",,,,"193","193",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VZV AB","40950076","CDM","302","RC","86787","HCPCS",,,"facility","inpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VZV AB","40950076","CDM","302","RC","86787","HCPCS",,,"facility","outpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PSA TOTAL SCREENING","40950077","CDM","301","RC","G0103","HCPCS",,,"facility","inpatient",,,,"249","249",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE PSA TOTAL SCREENING","40950077","CDM","301","RC","G0103","HCPCS",,,"facility","outpatient",,,,"244","244",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ENA AB","40950080","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ENA AB","40950080","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FLUOR AB SCRN EA AB TTR","40950086","CDM","302","RC","86256","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE FLUOR AB SCRN EA AB TTR","40950086","CDM","302","RC","86256","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VITAMIN D (125 DI HYDROX)","40950088","CDM","301","RC","82652","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE VITAMIN D (125 DI HYDROX)","40950088","CDM","301","RC","82652","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPATITIS PNL ACUTE","40950093","CDM","301","RC","80074","HCPCS",,,"facility","inpatient",,,,"391","391",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HEPATITIS PNL ACUTE","40950093","CDM","301","RC","80074","HCPCS",,,"facility","outpatient",,,,"391","391",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMIKACIN","40950095","CDM","301","RC","80150","HCPCS",,,"facility","inpatient",,,,"405","405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMIKACIN","40950095","CDM","301","RC","80150","HCPCS",,,"facility","outpatient",,,,"405","405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE METHOTREXATE","40950097","CDM","301","RC","80204","HCPCS",,,"facility","inpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE METHOTREXATE","40950097","CDM","301","RC","80204","HCPCS",,,"facility","outpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYPTOCOCCAL AG AGGL","40950098","CDM","302","RC","86403","HCPCS",,,"facility","inpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYPTOCOCCAL AG AGGL","40950098","CDM","302","RC","86403","HCPCS",,,"facility","outpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FLUID","40950100","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FLUID","40950100","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT CSF","40950101","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT CSF","40950101","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT GENITAL","40950103","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT GENITAL","40950103","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"322","322",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT UR ID EACH ISOLATE","40950109","CDM","306","RC","87088","HCPCS",,,"facility","inpatient",,,,"160","160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT UR ID EACH ISOLATE","40950109","CDM","306","RC","87088","HCPCS",,,"facility","outpatient",,,,"160","160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNGUS OTHER SOURCE","40950110","CDM","306","RC","87102","HCPCS",,,"facility","inpatient",,,,"175","175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNGUS OTHER SOURCE","40950110","CDM","306","RC","87102","HCPCS",,,"facility","outpatient",,,,"175","175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNGUS BLD","40950111","CDM","306","RC","87103","HCPCS",,,"facility","inpatient",,,,"311","311",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNGUS BLD","40950111","CDM","306","RC","87103","HCPCS",,,"facility","outpatient",,,,"311","311",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUSCEPT KB DISK <=12","40950112","CDM","306","RC","87184","HCPCS",,,"facility","inpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SUSCEPT KB DISK <=12","40950112","CDM","306","RC","87184","HCPCS",,,"facility","outpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SPEC CONCENTRATION","40950113","CDM","306","RC","87015","HCPCS",,,"facility","inpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE SPEC CONCENTRATION","40950113","CDM","306","RC","87015","HCPCS",,,"facility","outpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYPTOCOCCAL AG TTR AGGL","40950114","CDM","302","RC","86406","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CRYPTOCOCCAL AG TTR AGGL","40950114","CDM","302","RC","86406","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HISTONE AB","40950115","CDM","302","RC","86235","HCPCS",,,"facility","inpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE HISTONE AB","40950115","CDM","302","RC","86235","HCPCS",,,"facility","outpatient",,,,"139","139",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA DNA AMP PROBE","40950118","CDM","306","RC","87502","HCPCS",,,"facility","inpatient",,,,"640","640",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE INFLUENZA DNA AMP PROBE","40950118","CDM","306","RC","87502","HCPCS",,,"facility","outpatient",,,,"640","640",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASSAY OF LIPOPROTEIN(A)","40950119","CDM","301","RC","83695","HCPCS",,,"facility","inpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE ASSAY OF LIPOPROTEIN(A)","40950119","CDM","301","RC","83695","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CYCLIC CITRULLINATED PEPTIDE ANTIBODY","40950123","CDM","302","RC","86200","HCPCS",,,"facility","inpatient",,,,"53","53",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CYCLIC CITRULLINATED PEPTIDE ANTIBODY","40950123","CDM","302","RC","86200","HCPCS",,,"facility","outpatient",,,,"53","53",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TISS EXAM MOLECULAR STUDY","40950148","CDM","310","RC","88387","HCPCS",,,"facility","inpatient",,,,"1067","1067",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE TISS EXAM MOLECULAR STUDY","40950148","CDM","310","RC","88387","HCPCS",,,"facility","outpatient",,,,"1132","1132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMYLASE FLD","40950150","CDM","301","RC","82150","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE AMYLASE FLD","40950150","CDM","301","RC","82150","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT LEGIONELLA","40950155","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT LEGIONELLA","40950155","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNGUS MOLD ID","40950156","CDM","306","RC","87107","HCPCS",,,"facility","inpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE CULT FUNGUS MOLD ID","40950156","CDM","306","RC","87107","HCPCS",,,"facility","outpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE 2HR PP","40950164","CDM","301","RC","82950","HCPCS",,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE GLUCOSE 2HR PP","40950164","CDM","301","RC","82950","HCPCS",,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T LYMPH CD4/8 CNT&RATIO","40950165","CDM","302","RC","86360","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORE T LYMPH CD4/8 CNT&RATIO","40950165","CDM","302","RC","86360","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT OCCULT BLOOD STOOL QUALITATIVE  MULT SPEC DX","41050001","CDM","301","RC","82270","HCPCS",,,"facility","inpatient",,,,"96","96",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT OCCULT BLOOD STOOL QUALITATIVE  MULT SPEC DX","41050001","CDM","301","RC","82270","HCPCS",,,"facility","outpatient",,,,"96","96",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT ELECTROLYTE PANEL","41050002","CDM","301","RC","80051","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT ELECTROLYTE PANEL","41050002","CDM","301","RC","80051","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CREATININE","41050005","CDM","301","RC","82565","HCPCS",,,"facility","inpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CREATININE","41050005","CDM","301","RC","82565","HCPCS",,,"facility","outpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT GLUCOSE","41050006","CDM","301","RC","82947","HCPCS",,,"facility","inpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT GLUCOSE","41050006","CDM","301","RC","82947","HCPCS",,,"facility","outpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT REAGENT STRIP BLOOD GLUCOSE","41050007","CDM","301","RC","82948","HCPCS",,,"facility","inpatient",,,,"86","86",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT REAGENT STRIP BLOOD GLUCOSE","41050007","CDM","301","RC","82948","HCPCS",,,"facility","outpatient",,,,"86","86",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT POTASSIUM","41050010","CDM","301","RC","84132","HCPCS",,,"facility","inpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT POTASSIUM","41050010","CDM","301","RC","84132","HCPCS",,,"facility","outpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT SODIUM","41050011","CDM","301","RC","84295","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT SODIUM","41050011","CDM","301","RC","84295","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BLOOD GAS ANALYSIS","41050014","CDM","301","RC","82803","HCPCS",,,"facility","inpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BLOOD GAS ANALYSIS","41050014","CDM","301","RC","82803","HCPCS",,,"facility","outpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT HEMATOCRIT","41050015","CDM","305","RC","85014","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT HEMATOCRIT","41050015","CDM","305","RC","85014","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT HEMOGLOBIN","41050016","CDM","305","RC","85018","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT HEMOGLOBIN","41050016","CDM","305","RC","85018","HCPCS",,,"facility","outpatient",,,,"73","73",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CBC AUTO W/  AUTOMATED DIFFERENTIAL WBC","41050017","CDM","305","RC","85025","HCPCS",,,"facility","inpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CBC AUTO W/  AUTOMATED DIFFERENTIAL WBC","41050017","CDM","305","RC","85025","HCPCS",,,"facility","outpatient",,,,"210","210",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT ACTIVATED CLOTTING TIME","41050018","CDM","305","RC","85347","HCPCS",,,"facility","inpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT ACTIVATED CLOTTING TIME","41050018","CDM","305","RC","85347","HCPCS",,,"facility","outpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT PROTHROMBIN TIME","41050019","CDM","305","RC","85610","HCPCS",,,"facility","inpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT PROTHROMBIN TIME","41050019","CDM","305","RC","85610","HCPCS",,,"facility","outpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT URINALYSIS AUTO W/O MICRO","41050021","CDM","307","RC","81003","HCPCS",,,"facility","inpatient",,,,"102","102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT URINALYSIS AUTO W/O MICRO","41050021","CDM","307","RC","81003","HCPCS",,,"facility","outpatient",,,,"102","102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT PREGNANCY SCREEN URINE","41050022","CDM","307","RC","81025","HCPCS",,,"facility","inpatient",,,,"190","190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT PREGNANCY SCREEN URINE","41050022","CDM","307","RC","81025","HCPCS",,,"facility","outpatient",,,,"190","190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BLOOD GASES O2 SAT ONLY","41050023","CDM","301","RC","82810","HCPCS",,,"facility","inpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BLOOD GASES O2 SAT ONLY","41050023","CDM","301","RC","82810","HCPCS",,,"facility","outpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT LACTIC ACID","41050034","CDM","301","RC","83605","HCPCS",,,"facility","inpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT LACTIC ACID","41050034","CDM","301","RC","83605","HCPCS",,,"facility","outpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CALCIUM IONIZED","41050035","CDM","301","RC","82330","HCPCS",,,"facility","inpatient",,,,"218","218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CALCIUM IONIZED","41050035","CDM","301","RC","82330","HCPCS",,,"facility","outpatient",,,,"218","218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BSC MTBLC PNL INZD CA","41050037","CDM","301","RC","80047","HCPCS",,,"facility","inpatient",,,,"446","446",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BSC MTBLC PNL INZD CA","41050037","CDM","301","RC","80047","HCPCS",,,"facility","outpatient",,,,"446","446",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT URNALYSIS MAN W/O MICRO","41050038","CDM","307","RC","81002","HCPCS",,,"facility","inpatient",,,,"47","47",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT URNALYSIS MAN W/O MICRO","41050038","CDM","307","RC","81002","HCPCS",,,"facility","outpatient",,,,"47","47",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT OCCULT BLD 1-3 SPC NO NPLSM","41050039","CDM","301","RC","82272","HCPCS",,,"facility","inpatient",,,,"66","66",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT OCCULT BLD 1-3 SPC NO NPLSM","41050039","CDM","301","RC","82272","HCPCS",,,"facility","outpatient",,,,"66","66",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT PAMG-1 C/V QUAL EACH SPECIMEN","41050043","CDM","301","RC","84112","HCPCS",,,"facility","inpatient",,,,"489","489",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT PAMG-1 C/V QUAL EACH SPECIMEN","41050043","CDM","301","RC","84112","HCPCS",,,"facility","outpatient",,,,"489","489",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CARBOXYHEMOGLOBIN QN","41050044","CDM","301","RC","82375","HCPCS",,,"facility","inpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CARBOXYHEMOGLOBIN QN","41050044","CDM","301","RC","82375","HCPCS",,,"facility","outpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BLD GAS ART","41050045","CDM","301","RC","82803","HCPCS",,,"facility","inpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BLD GAS ART","41050045","CDM","301","RC","82803","HCPCS",,,"facility","outpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT PH BLD","41050047","CDM","301","RC","82800","HCPCS",,,"facility","inpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT PH BLD","41050047","CDM","301","RC","82800","HCPCS",,,"facility","outpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CHLORIDE","41050048","CDM","301","RC","82435","HCPCS",,,"facility","inpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT CHLORIDE","41050048","CDM","301","RC","82435","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT HEPARIN ASSAY","41050049","CDM","305","RC","85520","HCPCS",,,"facility","inpatient",,,,"398","398",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT HEPARIN ASSAY","41050049","CDM","305","RC","85520","HCPCS",,,"facility","outpatient",,,,"398","398",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT METHEMOGLOBIN","41050050","CDM","301","RC","83050","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT METHEMOGLOBIN","41050050","CDM","301","RC","83050","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BLOOD GAS CAPILLARY","41050052","CDM","301","RC","82803","HCPCS",,,"facility","inpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT BLOOD GAS CAPILLARY","41050052","CDM","301","RC","82803","HCPCS",,,"facility","outpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT HEMOGLOBIN GLYCOSYLATED A1C","41050057","CDM","301","RC","83036","HCPCS",,,"facility","inpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT HEMOGLOBIN GLYCOSYLATED A1C","41050057","CDM","301","RC","83036","HCPCS",,,"facility","outpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POCT IADNA SARS-COV-2 COVID-19 AMP PROBE TQ","41050063","CDM","306","RC","87635","HCPCS",,,"facility","inpatient",,,"QW","382","382",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"HCHG POCT IADNA SARS-COV-2 COVID-19 AMP PROBE TQ","41050063","CDM","306","RC","87635","HCPCS",,,"facility","outpatient",,,"QW","382","382",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"HCHG AUTOLOGOUS PROCESSING AND STORAGE","41100000","CDM","390","RC","86890","HCPCS",,,"facility","inpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AUTOLOGOUS PROCESSING AND STORAGE","41100000","CDM","390","RC","86890","HCPCS",,,"facility","outpatient",,,,"336","336",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WHOLE BLOOD PROCESSING EA UNIT","41100001","CDM","390","RC","P9010","HCPCS",,,"facility","inpatient",,,,"276","276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WHOLE BLOOD PROCESSING EA UNIT","41100001","CDM","390","RC","P9010","HCPCS",,,"facility","outpatient",,,,"276","276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYO PS (POOLED CRYO (5 CRYO))","41100002","CDM","390","RC","P9012","HCPCS",,,"facility","inpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYO PS (POOLED CRYO (5 CRYO))","41100002","CDM","390","RC","P9012","HCPCS",,,"facility","outpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC LEUKOCYTES REDUCED PROCESSING EA UNIT","41100003","CDM","390","RC","P9016","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC LEUKOCYTES REDUCED PROCESSING EA UNIT","41100003","CDM","390","RC","P9016","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRESH FROZEN PLASMA PROCESSING EA UNIT","41100004","CDM","390","RC","P9017","HCPCS",,,"facility","inpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRESH FROZEN PLASMA PROCESSING EA UNIT","41100004","CDM","390","RC","P9017","HCPCS",,,"facility","outpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS EA UNIT  PROCESSING EA UNIT","41100005","CDM","390","RC","P9019","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS EA UNIT  PROCESSING EA UNIT","41100005","CDM","390","RC","P9019","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELET RICH PLASMA PROCESSING EA UNIT","41100006","CDM","390","RC","P9020","HCPCS",,,"facility","inpatient",,,,"450","450",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELET RICH PLASMA PROCESSING EA UNIT","41100006","CDM","390","RC","P9020","HCPCS",,,"facility","outpatient",,,,"450","450",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GRANULOCYTES PHERESIS","41100007","CDM","390","RC","P9050","HCPCS",,,"facility","inpatient",,,"GY","2048","2048",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG GRANULOCYTES PHERESIS","41100007","CDM","390","RC","P9050","HCPCS",,,"facility","outpatient",,,"GY","2048","2048",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG WASHED RBC PROCESSING EA UNIT","41100008","CDM","390","RC","P9022","HCPCS",,,"facility","inpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WASHED RBC PROCESSING EA UNIT","41100008","CDM","390","RC","P9022","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS LEUKOCYTES REDUCED PROCESSING EA UNIT","41100010","CDM","390","RC","P9031","HCPCS",,,"facility","inpatient",,,,"347","347",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS LEUKOCYTES REDUCED PROCESSING EA UNIT","41100010","CDM","390","RC","P9031","HCPCS",,,"facility","outpatient",,,,"347","347",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS IRRADIATED PROCESSING EA UNIT","41100011","CDM","390","RC","P9032","HCPCS",,,"facility","inpatient",,,,"500","500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS IRRADIATED PROCESSING EA UNIT","41100011","CDM","390","RC","P9032","HCPCS",,,"facility","outpatient",,,,"500","500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS PROCESSING EA UNIT","41100012","CDM","390","RC","P9034","HCPCS",,,"facility","inpatient",,,,"481","481",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS PROCESSING EA UNIT","41100012","CDM","390","RC","P9034","HCPCS",,,"facility","outpatient",,,,"481","481",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS LEUKOCYTE REDUCED EA UNIT","41100013","CDM","390","RC","P9035","HCPCS",,,"facility","inpatient",,,,"481","481",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS LEUKOCYTE REDUCED EA UNIT","41100013","CDM","390","RC","P9035","HCPCS",,,"facility","outpatient",,,,"481","481",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS IRRADIATED PROCESSING EA UNIT","41100014","CDM","390","RC","P9036","HCPCS",,,"facility","inpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS IRRADIATED PROCESSING EA UNIT","41100014","CDM","390","RC","P9036","HCPCS",,,"facility","outpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHER L/R IRRAD PS EA UNIT","41100015","CDM","390","RC","P9037","HCPCS",,,"facility","inpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHER L/R IRRAD PS EA UNIT","41100015","CDM","390","RC","P9037","HCPCS",,,"facility","outpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC DEGLYCEROLIZED PROCESSING EA UNIT","41100016","CDM","390","RC","P9039","HCPCS",,,"facility","inpatient",,,,"367","367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC DEGLYCEROLIZED PROCESSING EA UNIT","41100016","CDM","390","RC","P9039","HCPCS",,,"facility","outpatient",,,,"367","367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC LEUKOCYTE REDUCED IRRAD PS EA UNIT","41100017","CDM","390","RC","P9040","HCPCS",,,"facility","inpatient",,,,"273","273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC LEUKOCYTE REDUCED IRRAD PS EA UNIT","41100017","CDM","390","RC","P9040","HCPCS",,,"facility","outpatient",,,,"273","273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLASMA CRYOPRECIPITATE REDUCED PROCESSING EA UNIT","41100018","CDM","390","RC","P9044","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLASMA CRYOPRECIPITATE REDUCED PROCESSING EA UNIT","41100018","CDM","390","RC","P9044","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERSIS L/R HLA MATCHED PROCESSING EA UNIT","41100019","CDM","390","RC","P9052","HCPCS",,,"facility","inpatient",,,,"744","744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERSIS L/R HLA MATCHED PROCESSING EA UNIT","41100019","CDM","390","RC","P9052","HCPCS",,,"facility","outpatient",,,,"744","744",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC FROZEN LEUKOCYTE REDUCED DEGLYCEROL/WASHED PS EA UNIT","41100020","CDM","390","RC","P9054","HCPCS",,,"facility","inpatient",,,,"420","420",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC FROZEN LEUKOCYTE REDUCED DEGLYCEROL/WASHED PS EA UNIT","41100020","CDM","390","RC","P9054","HCPCS",,,"facility","outpatient",,,,"420","420",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC FROZEN/DEGLYCEROLIZED/WASHED LR IRRADIATED PS EA UNIT","41100021","CDM","390","RC","P9057","HCPCS",,,"facility","inpatient",,,,"420","420",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC FROZEN/DEGLYCEROLIZED/WASHED LR IRRADIATED PS EA UNIT","41100021","CDM","390","RC","P9057","HCPCS",,,"facility","outpatient",,,,"420","420",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRESH FROZEN PLASMA 8-24 HRS OF COLLECTION EA UNIT","41100022","CDM","390","RC","P9059","HCPCS",,,"facility","inpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRESH FROZEN PLASMA 8-24 HRS OF COLLECTION EA UNIT","41100022","CDM","390","RC","P9059","HCPCS",,,"facility","outpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC PROCESSING","41100023","CDM","390","RC","P9021","HCPCS",,,"facility","inpatient",,,,"788","788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC PROCESSING","41100023","CDM","390","RC","P9021","HCPCS",,,"facility","outpatient",,,,"788","788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHER L/R CMV NEG IRR PS EA UNIT","41100027","CDM","390","RC","P9053","HCPCS",,,"facility","inpatient",,,,"576","576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHER L/R CMV NEG IRR PS EA UNIT","41100027","CDM","390","RC","P9053","HCPCS",,,"facility","outpatient",,,,"576","576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHER L/R CMV NEG PS","41100028","CDM","390","RC","P9055","HCPCS",,,"facility","inpatient",,,,"523","523",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHER L/R CMV NEG PS","41100028","CDM","390","RC","P9055","HCPCS",,,"facility","outpatient",,,,"523","523",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRESH FROZEN PLASMA PROCESSING JUMBO EA UNIT","41100029","CDM","390","RC","P9017","HCPCS",,,"facility","inpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRESH FROZEN PLASMA PROCESSING JUMBO EA UNIT","41100029","CDM","390","RC","P9017","HCPCS",,,"facility","outpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYO PS SINGLE UNIT","41100055","CDM","390","RC","P9012","HCPCS",,,"facility","inpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYO PS SINGLE UNIT","41100055","CDM","390","RC","P9012","HCPCS",,,"facility","outpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRESH FROZEN PLAZMA PROCESSING DIVIDED UNIT","41100056","CDM","390","RC","P9017","HCPCS",,,"facility","inpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FRESH FROZEN PLAZMA PROCESSING DIVIDED UNIT","41100056","CDM","390","RC","P9017","HCPCS",,,"facility","outpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THAWING FRZN BLD","41100057","CDM","302","RC","86931","HCPCS",,,"facility","inpatient",,,,"355","355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THAWING FRZN BLD","41100057","CDM","302","RC","86931","HCPCS",,,"facility","outpatient",,,,"355","355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD SPLIT UNIT PS","41100058","CDM","390","RC","P9011","HCPCS",,,"facility","inpatient",,,,"298","298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD SPLIT UNIT PS","41100058","CDM","390","RC","P9011","HCPCS",,,"facility","outpatient",,,,"298","298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC IRRADIATED PS","41100059","CDM","390","RC","P9038","HCPCS",,,"facility","inpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC IRRADIATED PS","41100059","CDM","390","RC","P9038","HCPCS",,,"facility","outpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC LEUKOCYTES REDUCED PROCESSING DIVIDED UNIT","41100060","CDM","390","RC","P9016","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC LEUKOCYTES REDUCED PROCESSING DIVIDED UNIT","41100060","CDM","390","RC","P9016","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC L/R CMV NEG IRR PS DIVIDED UNIT","41100061","CDM","390","RC","P9058","HCPCS",,,"facility","inpatient",,,,"315","315",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC L/R CMV NEG IRR PS DIVIDED UNIT","41100061","CDM","390","RC","P9058","HCPCS",,,"facility","outpatient",,,,"315","315",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHER L/R IRRAD PS DIVIDED UNIT","41100062","CDM","390","RC","P9037","HCPCS",,,"facility","inpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHER L/R IRRAD PS DIVIDED UNIT","41100062","CDM","390","RC","P9037","HCPCS",,,"facility","outpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC LEUKOCYTE REDUCED IRRAD PS DIVIDED UNIT","41100063","CDM","390","RC","P9040","HCPCS",,,"facility","inpatient",,,,"273","273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC LEUKOCYTE REDUCED IRRAD PS DIVIDED UNIT","41100063","CDM","390","RC","P9040","HCPCS",,,"facility","outpatient",,,,"273","273",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHER L/R CMV NEG IRR PS DIVIDED UNIT","41100064","CDM","390","RC","P9053","HCPCS",,,"facility","inpatient",,,,"576","576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHER L/R CMV NEG IRR PS DIVIDED UNIT","41100064","CDM","390","RC","P9053","HCPCS",,,"facility","outpatient",,,,"576","576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC L/R CMV NEG PS EACH UNIT","41100065","CDM","390","RC","P9051","HCPCS",,,"facility","inpatient",,,,"262","262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC L/R CMV NEG PS EACH UNIT","41100065","CDM","390","RC","P9051","HCPCS",,,"facility","outpatient",,,,"262","262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLTC L/R IRRADIATED PS","41100066","CDM","390","RC","P9033","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLTC L/R IRRADIATED PS","41100066","CDM","390","RC","P9033","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS LEUKOCYTE REDUCED DIVIDED","41100067","CDM","390","RC","P9035","HCPCS",,,"facility","inpatient",,,,"936","936",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS LEUKOCYTE REDUCED DIVIDED","41100067","CDM","390","RC","P9035","HCPCS",,,"facility","outpatient",,,,"936","936",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIQUID PLASMA CRYOPPT REDUCED EACH UNIT","41100068","CDM","390","RC","P9044","HCPCS",,,"facility","inpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIQUID PLASMA CRYOPPT REDUCED EACH UNIT","41100068","CDM","390","RC","P9044","HCPCS",,,"facility","outpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT","41100069","CDM","390","RC","P9073","HCPCS",,,"facility","inpatient",,,,"944","944",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHERESIS PATHOGEN-REDUCED EACH UNIT","41100069","CDM","390","RC","P9073","HCPCS",,,"facility","outpatient",,,,"944","944",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PATHOGEN TESTING","41100070","CDM","300","RC","P9100","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PATHOGEN TESTING","41100070","CDM","300","RC","P9100","HCPCS",,,"facility","outpatient",,,,"124","124",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLASMA FRESH FROZEN CONVALESCENT","41100071","CDM","390","RC","P9017","HCPCS",,,"facility","inpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLASMA FRESH FROZEN CONVALESCENT","41100071","CDM","390","RC","P9017","HCPCS",,,"facility","outpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHER L/R LVDS PS EA UNIT","41100072","CDM","390","RC","P9035","HCPCS",,,"facility","inpatient",,,,"936","936",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHER L/R LVDS PS EA UNIT","41100072","CDM","390","RC","P9035","HCPCS",,,"facility","outpatient",,,,"936","936",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHER L/R IRRAD LVDS PS EA UNIT","41100073","CDM","390","RC","P9037","HCPCS",,,"facility","inpatient",,,,"1116","1116",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELETS PHER L/R IRRAD LVDS PS EA UNIT","41100073","CDM","390","RC","P9037","HCPCS",,,"facility","outpatient",,,,"1116","1116",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC L/R IRRADIATED FOR RCNSTITUTE PROC EA UNIT","41100074","CDM","390","RC","P9040","HCPCS",,,"facility","inpatient",,,,"562","562",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC L/R IRRADIATED FOR RCNSTITUTE PROC EA UNIT","41100074","CDM","390","RC","P9040","HCPCS",,,"facility","outpatient",,,,"562","562",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FFP 8-24 HRS OF COLL FOR RCNSTITUT PROC EA UNIT","41100075","CDM","390","RC","P9059","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FFP 8-24 HRS OF COLL FOR RCNSTITUT PROC EA UNIT","41100075","CDM","390","RC","P9059","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF ER/PR/HER-2 W/MORPHOMETRY","41200000","CDM","310","RC","88360","HCPCS",,,"facility","inpatient",,,,"276","276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF ER/PR/HER-2 W/MORPHOMETRY","41200000","CDM","310","RC","88360","HCPCS",,,"facility","outpatient",,,,"276","276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO TUMOR IMMUNOHISTOCHEM MAN","41200001","CDM","310","RC","88360","HCPCS",,,"facility","inpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO TUMOR IMMUNOHISTOCHEM MAN","41200001","CDM","310","RC","88360","HCPCS",,,"facility","outpatient",,,,"60.5","60.5",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF TMR IMMUNOHIST W/COM ASST","41200002","CDM","310","RC","88361","HCPCS",,,"facility","inpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF TMR IMMUNOHIST W/COM ASST","41200002","CDM","310","RC","88361","HCPCS",,,"facility","outpatient",,,,"77","77",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF XM ARCHIV TISS MOLEC ANAL","41200003","CDM","310","RC","88363","HCPCS",,,"facility","inpatient",,,,"22.79","22.79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF XM ARCHIV TISS MOLEC ANAL","41200003","CDM","310","RC","88363","HCPCS",,,"facility","outpatient",,,,"22.79","22.79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF IN SITU HYBRIDIZATION EA PROBE","41200004","CDM","310","RC","88365","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF IN SITU HYBRIDIZATION EA PROBE","41200004","CDM","310","RC","88365","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO IN SITU HYBRIDIZATION EA PROBE","41200005","CDM","310","RC","88365","HCPCS",,,"facility","inpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO IN SITU HYBRIDIZATION EA PROBE","41200005","CDM","310","RC","88365","HCPCS",,,"facility","outpatient",,,,"72","72",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF MORPHOMETRIC ANLYS IN SITU HYBRIDIZATN EA PRB AUTO","41200006","CDM","310","RC","88367","HCPCS",,,"facility","inpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF MORPHOMETRIC ANLYS IN SITU HYBRIDIZATN EA PRB AUTO","41200006","CDM","310","RC","88367","HCPCS",,,"facility","outpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO INSITU HYBRIDIZATION AUTO","41200007","CDM","310","RC","88367","HCPCS",,,"facility","inpatient",,,,"240","240",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO INSITU HYBRIDIZATION AUTO","41200007","CDM","310","RC","88367","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF MORPHOMETRC ANLYS IN SITU HYBRIDIZTN EA PRB MANUAL","41200008","CDM","310","RC","88368","HCPCS",,,"facility","inpatient",,,,"198","198",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF MORPHOMETRC ANLYS IN SITU HYBRIDIZTN EA PRB MANUAL","41200008","CDM","310","RC","88368","HCPCS",,,"facility","outpatient",,,,"198","198",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO INSITU HYBRIDIZATION MANUAL","41200010","CDM","310","RC","88368","HCPCS",,,"facility","inpatient",,,,"240","240",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO INSITU HYBRIDIZATION MANUAL","41200010","CDM","310","RC","88368","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS","41200043","CDM","311","RC","88182","HCPCS",,,"facility","inpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS","41200043","CDM","311","RC","88182","HCPCS",,,"facility","outpatient",,,,"60.5","60.5",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF DNA ANALYSIS","41200045","CDM","311","RC","88182","HCPCS",,,"facility","inpatient",,,,"268.46","268.46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF DNA ANALYSIS","41200045","CDM","311","RC","88182","HCPCS",,,"facility","outpatient",,,,"147.65","147.65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER TECH ONLY 1ST","41200046","CDM","311","RC","88184","HCPCS",,,"facility","inpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER TECH ONLY 1ST","41200046","CDM","311","RC","88184","HCPCS",,,"facility","outpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER TECHNICAL COMPONENT EA ADDL MARKER","41200047","CDM","311","RC","88185","HCPCS",,,"facility","inpatient",,,,"23","23",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER TECHNICAL COMPONENT EA ADDL MARKER","41200047","CDM","311","RC","88185","HCPCS",,,"facility","outpatient",,,,"19","19",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER INTERPRETATION 2-8 MARKERS","41200050","CDM","311","RC","88187","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER INTERPRETATION 2-8 MARKERS","41200050","CDM","311","RC","88187","HCPCS",,,"facility","outpatient",,,,"66","66",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER INTERPRET 9-15 MARKERS","41200052","CDM","311","RC","88188","HCPCS",,,"facility","inpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER INTERPRET 9-15 MARKERS","41200052","CDM","311","RC","88188","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER INTERPRET 16+","41200054","CDM","311","RC","88189","HCPCS",,,"facility","inpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CELL MARKER INTERPRET 16+","41200054","CDM","311","RC","88189","HCPCS",,,"facility","outpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF NEO CELL MARKER INTERPRET 16+","41200056","CDM","311","RC","88189","HCPCS",,,"facility","outpatient",,,,"82.5","82.5",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CYTP UR 3-5 PROBES CMPTR","41200058","CDM","311","RC","88121","HCPCS",,,"facility","inpatient",,,,"550","550",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CYTP UR 3-5 PROBES CMPTR","41200058","CDM","311","RC","88121","HCPCS",,,"facility","outpatient",,,,"302.5","302.5",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CYTO CL BLK 5 CNT/1 KARY","41200062","CDM","312","RC","88305","HCPCS",,,"facility","inpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CYTO CL BLK 5 CNT/1 KARY","41200062","CDM","312","RC","88305","HCPCS",,,"facility","outpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SURGICAL PATHOLOGY LEVEL IV","41200063","CDM","312","RC","88305","HCPCS",,,"facility","inpatient",,,,"340","340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SURGICAL PATHOLOGY LEVEL IV","41200063","CDM","312","RC","88305","HCPCS",,,"facility","outpatient",,,,"187","187",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SPECIAL STAIN I&R GROUP I MICROORGANISM","41200067","CDM","312","RC","88312","HCPCS",,,"facility","inpatient",,,,"173","173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SPECIAL STAIN I&R GROUP I MICROORGANISM","41200067","CDM","312","RC","88312","HCPCS",,,"facility","outpatient",,,,"173","173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SPCL STN I&R GRP II NO MICROORG/ENZYME/IMCYT&IS","41200068","CDM","312","RC","88313","HCPCS",,,"facility","inpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SPCL STN I&R GRP II NO MICROORG/ENZYME/IMCYT&IS","41200068","CDM","312","RC","88313","HCPCS",,,"facility","outpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SPCL STAIN I&R HSTOCHEM STN ON FRZN TISS BLOCK","41200070","CDM","312","RC","88314","HCPCS",,,"facility","inpatient",,,,"200","200",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SPCL STAIN I&R HSTOCHEM STN ON FRZN TISS BLOCK","41200070","CDM","312","RC","88314","HCPCS",,,"facility","outpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SPECIAL STAIN I&R GROUP III ENZYME CONSTITUENTS","41200071","CDM","312","RC","88319","HCPCS",,,"facility","inpatient",,,,"240","240",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SPECIAL STAIN I&R GROUP III ENZYME CONSTITUENTS","41200071","CDM","312","RC","88319","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF OUTSD SLIDE CONSULT","41200072","CDM","312","RC","88321","HCPCS",,,"facility","inpatient",,,,"181","181",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF OUTSD SLIDE CONSULT","41200072","CDM","312","RC","88321","HCPCS",,,"facility","outpatient",,,,"181","181",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CONSULT/RPRT REFERRED SLIDES REQUIRING SLIDE PP","41200073","CDM","312","RC","88323","HCPCS",,,"facility","inpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CONSULT/RPRT REFERRED SLIDES REQUIRING SLIDE PP","41200073","CDM","312","RC","88323","HCPCS",,,"facility","outpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF PATH FRZN SECTION ADD","41200077","CDM","312","RC","88332","HCPCS",,,"facility","inpatient",,,,"92","92",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF PATH FRZN SECTION ADD","41200077","CDM","312","RC","88332","HCPCS",,,"facility","outpatient",,,,"92","92",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF ELECTRON MICROSCOPY DIAGNOSTIC","41200085","CDM","312","RC","88348","HCPCS",,,"facility","inpatient",,,,"1414","1414",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF ELECTRON MICROSCOPY DIAGNOSTIC","41200085","CDM","312","RC","88348","HCPCS",,,"facility","outpatient",,,,"1414","1414",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CYTOPATHOLOGY URINE 3-5  PROBES EA SPEC MANUAL","41200104","CDM","311","RC","88120","HCPCS",,,"facility","inpatient",,,,"550","550",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CYTOPATHOLOGY URINE 3-5  PROBES EA SPEC MANUAL","41200104","CDM","311","RC","88120","HCPCS",,,"facility","outpatient",,,,"302.5","302.5",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF TISSUE CULTURE LYMPHOCYTE","41200105","CDM","311","RC","88230","HCPCS",,,"facility","inpatient",,,,"128.8","128.8",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF TISSUE CULTURE LYMPHOCYTE","41200105","CDM","311","RC","88230","HCPCS",,,"facility","outpatient",,,,"128.8","128.8",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF TISSUE CULTURE OTHER TISSUE","41200111","CDM","311","RC","88239","HCPCS",,,"facility","inpatient",,,,"412.24","412.24",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF TISSUE CULTURE OTHER TISSUE","41200111","CDM","311","RC","88239","HCPCS",,,"facility","outpatient",,,,"226.73","226.73",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CHR0MOSOME COUNT KARYOTYPE 5 CELLS/ 1 KARYOTYPE","41200114","CDM","311","RC","88261","HCPCS",,,"facility","inpatient",,,,"493.86","493.86",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CHR0MOSOME COUNT KARYOTYPE 5 CELLS/ 1 KARYOTYPE","41200114","CDM","311","RC","88261","HCPCS",,,"facility","outpatient",,,,"271.62","271.62",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CHRMOSOME COUNT 15-20 CELLS/ 1 KARYOTYPE","41200116","CDM","311","RC","88262","HCPCS",,,"facility","inpatient",,,,"348","348",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CHRMOSOME COUNT 15-20 CELLS/ 1 KARYOTYPE","41200116","CDM","311","RC","88262","HCPCS",,,"facility","outpatient",,,,"192","192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF DNA PROBE CYTOGENETICS EA","41200124","CDM","311","RC","88271","HCPCS",,,"facility","inpatient",,,,"35","35",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF DNA PROBE CYTOGENETICS EA","41200124","CDM","311","RC","88271","HCPCS",,,"facility","outpatient",,,,"35","35",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF DNA PROBE CYTOGENETICS >100","41200128","CDM","311","RC","88275","HCPCS",,,"facility","inpatient",,,,"59","59",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF DNA PROBE CYTOGENETICS >100","41200128","CDM","311","RC","88275","HCPCS",,,"facility","outpatient",,,,"59","59",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CHRMOSOM ADD CL CNT EA","41200133","CDM","312","RC","88285","HCPCS",,,"facility","inpatient",,,,"53.08","53.08",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF CHRMOSOM ADD CL CNT EA","41200133","CDM","312","RC","88285","HCPCS",,,"facility","outpatient",,,,"29.19","29.19",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF  INSITU HYBRIDIZATION (FISH) EA ADD","41200138","CDM","310","RC","88364","HCPCS",,,"facility","inpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF  INSITU HYBRIDIZATION (FISH) EA ADD","41200138","CDM","310","RC","88364","HCPCS",,,"facility","outpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SITU HYBRID MANUAL EA ADD","41200140","CDM","310","RC","88369","HCPCS",,,"facility","inpatient",,,,"500","500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SITU HYBRID MANUAL EA ADD","41200140","CDM","310","RC","88369","HCPCS",,,"facility","outpatient",,,,"500","500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF INSITU HYBRIDIZATION (FISH) EA MULTI","41200141","CDM","310","RC","88366","HCPCS",,,"facility","inpatient",,,,"500","500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF INSITU HYBRIDIZATION (FISH) EA MULTI","41200141","CDM","310","RC","88366","HCPCS",,,"facility","outpatient",,,,"500","500",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SITU HYBRID MANUAL EA ADD MULTI","41200143","CDM","310","RC","88377","HCPCS",,,"facility","inpatient",,,,"281","281",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF SITU HYBRID MANUAL EA ADD MULTI","41200143","CDM","310","RC","88377","HCPCS",,,"facility","outpatient",,,,"281","281",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF IMMUNOHISTO AB STAIN INITIAL SINGLE AB","41200144","CDM","310","RC","88342","HCPCS",,,"facility","inpatient",,,,"246","246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF IMMUNOHISTO AB STAIN INITIAL SINGLE AB","41200144","CDM","310","RC","88342","HCPCS",,,"facility","outpatient",,,,"246","246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF IMMUNOHISTO ANTIBODY SLIDE EA ADD","41200145","CDM","310","RC","88341","HCPCS",,,"facility","inpatient",,,,"170","170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF IMMUNOHISTO ANTIBODY SLIDE EA ADD","41200145","CDM","310","RC","88341","HCPCS",,,"facility","outpatient",,,,"170","170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF IMMUNOHISTO ANTIBODY SLIDE MULTI","41200146","CDM","310","RC","88344","HCPCS",,,"facility","inpatient",,,,"370","370",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REF IMMUNOHISTO ANTIBODY SLIDE MULTI","41200146","CDM","310","RC","88344","HCPCS",,,"facility","outpatient",,,,"370","370",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BASIC METABOLIC PANEL","42000000","CDM","301","RC","80048","HCPCS",,,"facility","inpatient",,,,"383","383",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BASIC METABOLIC PANEL","42000000","CDM","301","RC","80048","HCPCS",,,"facility","outpatient",,,,"310","310",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENERAL HEALTH PANEL","42000001","CDM","301","RC","80050","HCPCS",,,"facility","inpatient",,,"GY","595","595",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG GENERAL HEALTH PANEL","42000001","CDM","301","RC","80050","HCPCS",,,"facility","outpatient",,,"GY","595","595",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG ELECTROLYTE PANEL","42000002","CDM","301","RC","80051","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELECTROLYTE PANEL","42000002","CDM","301","RC","80051","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRENATAL OBSTETRIC PANEL W/HIV","42000003","CDM","301","RC","80081","HCPCS",,,"facility","inpatient",,,,"1009","1009",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRENATAL OBSTETRIC PANEL W/HIV","42000003","CDM","301","RC","80081","HCPCS",,,"facility","outpatient",,,,"1009","1009",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPREHENSIVE METABOLIC PANEL","42000004","CDM","301","RC","80053","HCPCS",,,"facility","inpatient",,,,"471","471",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPREHENSIVE METABOLIC PANEL","42000004","CDM","301","RC","80053","HCPCS",,,"facility","outpatient",,,,"386","386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRENATAL PANEL","42000005","CDM","301","RC","80055","HCPCS",,,"facility","inpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PRENATAL PANEL","42000005","CDM","301","RC","80055","HCPCS",,,"facility","outpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIPID PANEL","42000006","CDM","301","RC","80061","HCPCS",,,"facility","inpatient",,,,"343","343",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIPID PANEL","42000006","CDM","301","RC","80061","HCPCS",,,"facility","outpatient",,,,"343","343",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RENAL FUNCTION PANEL","42000007","CDM","301","RC","80069","HCPCS",,,"facility","inpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RENAL FUNCTION PANEL","42000007","CDM","301","RC","80069","HCPCS",,,"facility","outpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATIC FUNCTION PANEL","42000009","CDM","301","RC","80076","HCPCS",,,"facility","inpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATIC FUNCTION PANEL","42000009","CDM","301","RC","80076","HCPCS",,,"facility","outpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TEST BLOOD FECAL ASSAY","42000101","CDM","301","RC","82274","HCPCS",,,"facility","inpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TEST BLOOD FECAL ASSAY","42000101","CDM","301","RC","82274","HCPCS",,,"facility","outpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMIKACIN","42050000","CDM","301","RC","80150","HCPCS",,,"facility","inpatient",,,,"405","405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMIKACIN","42050000","CDM","301","RC","80150","HCPCS",,,"facility","outpatient",,,,"405","405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARBAMAZEPINE TOTAL","42050006","CDM","301","RC","80156","HCPCS",,,"facility","inpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARBAMAZEPINE TOTAL","42050006","CDM","301","RC","80156","HCPCS",,,"facility","outpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIGOXIN TOTAL","42050010","CDM","301","RC","80162","HCPCS",,,"facility","inpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIGOXIN TOTAL","42050010","CDM","301","RC","80162","HCPCS",,,"facility","outpatient",,,,"361","361",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VALPROIC ACID TOTAL","42050011","CDM","301","RC","80164","HCPCS",,,"facility","inpatient",,,,"406","406",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VALPROIC ACID TOTAL","42050011","CDM","301","RC","80164","HCPCS",,,"facility","outpatient",,,,"406","406",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENTAMICIN PEAK","42050014","CDM","301","RC","80170","HCPCS",,,"facility","inpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENTAMICIN PEAK","42050014","CDM","301","RC","80170","HCPCS",,,"facility","outpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENTAMICIN RANDOM","42050015","CDM","301","RC","80170","HCPCS",,,"facility","inpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENTAMICIN RANDOM","42050015","CDM","301","RC","80170","HCPCS",,,"facility","outpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENTAMICIN TROUGH","42050016","CDM","301","RC","80170","HCPCS",,,"facility","inpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENTAMICIN TROUGH","42050016","CDM","301","RC","80170","HCPCS",,,"facility","outpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIDOCAINE","42050020","CDM","301","RC","80176","HCPCS",,,"facility","inpatient",,,,"395","395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIDOCAINE","42050020","CDM","301","RC","80176","HCPCS",,,"facility","outpatient",,,,"395","395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LITHIUM","42050021","CDM","301","RC","80178","HCPCS",,,"facility","inpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LITHIUM","42050021","CDM","301","RC","80178","HCPCS",,,"facility","outpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHENOBARBITAL","42050023","CDM","301","RC","80184","HCPCS",,,"facility","inpatient",,,,"314","314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHENOBARBITAL","42050023","CDM","301","RC","80184","HCPCS",,,"facility","outpatient",,,,"314","314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHENYTOIN TOTAL","42050024","CDM","301","RC","80185","HCPCS",,,"facility","inpatient",,,,"384","384",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHENYTOIN TOTAL","42050024","CDM","301","RC","80185","HCPCS",,,"facility","outpatient",,,,"384","384",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHENYTOIN FREE","42050025","CDM","301","RC","80186","HCPCS",,,"facility","inpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHENYTOIN FREE","42050025","CDM","301","RC","80186","HCPCS",,,"facility","outpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG QUINIDINE","42050029","CDM","301","RC","80194","HCPCS",,,"facility","inpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG QUINIDINE","42050029","CDM","301","RC","80194","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SIROLIMUS","42050030","CDM","301","RC","80195","HCPCS",,,"facility","inpatient",,,,"164","164",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SIROLIMUS","42050030","CDM","301","RC","80195","HCPCS",,,"facility","outpatient",,,,"164","164",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SALICYLATE","42050031","CDM","301","RC","80179","HCPCS",,,"facility","inpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SALICYLATE","42050031","CDM","301","RC","80179","HCPCS",,,"facility","outpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TACROLIMUS (FK506)","42050032","CDM","301","RC","80197","HCPCS",,,"facility","inpatient",,,,"152","152",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TACROLIMUS (FK506)","42050032","CDM","301","RC","80197","HCPCS",,,"facility","outpatient",,,,"152","152",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THEOPHYLLINE","42050033","CDM","301","RC","80198","HCPCS",,,"facility","inpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THEOPHYLLINE","42050033","CDM","301","RC","80198","HCPCS",,,"facility","outpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOBRAMYCIN PEAK","42050034","CDM","301","RC","80200","HCPCS",,,"facility","inpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOBRAMYCIN PEAK","42050034","CDM","301","RC","80200","HCPCS",,,"facility","outpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOBRAMYCIN RANDOM","42050035","CDM","301","RC","80200","HCPCS",,,"facility","inpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOBRAMYCIN RANDOM","42050035","CDM","301","RC","80200","HCPCS",,,"facility","outpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOBRAMYCIN TROUGH","42050036","CDM","301","RC","80200","HCPCS",,,"facility","inpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOBRAMYCIN TROUGH","42050036","CDM","301","RC","80200","HCPCS",,,"facility","outpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VANCOMYCIN PEAK","42050038","CDM","301","RC","80202","HCPCS",,,"facility","inpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VANCOMYCIN PEAK","42050038","CDM","301","RC","80202","HCPCS",,,"facility","outpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VANCOMYCIN RANDOM","42050039","CDM","301","RC","80202","HCPCS",,,"facility","inpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VANCOMYCIN RANDOM","42050039","CDM","301","RC","80202","HCPCS",,,"facility","outpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VANCOMYCIN TROUGH","42050040","CDM","301","RC","80202","HCPCS",,,"facility","inpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VANCOMYCIN TROUGH","42050040","CDM","301","RC","80202","HCPCS",,,"facility","outpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAFFEINE","42050043","CDM","301","RC","80299","HCPCS",,,"facility","inpatient",,,,"255","255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAFFEINE","42050043","CDM","301","RC","80299","HCPCS",,,"facility","outpatient",,,,"255","255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG METHOTREXATE","42050059","CDM","301","RC","80204","HCPCS",,,"facility","inpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG METHOTREXATE","42050059","CDM","301","RC","80204","HCPCS",,,"facility","outpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYCLOSPORINE","42050082","CDM","301","RC","80158","HCPCS",,,"facility","inpatient",,,,"246","246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYCLOSPORINE","42050082","CDM","301","RC","80158","HCPCS",,,"facility","outpatient",,,,"246","246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ACETAMINOPHEN","42100000","CDM","301","RC","80143","HCPCS",,,"facility","inpatient",,,,"325","325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ACETAMINOPHEN","42100000","CDM","301","RC","80143","HCPCS",,,"facility","outpatient",,,,"325","325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KETONES QUALITATIVE","42100001","CDM","301","RC","82009","HCPCS",,,"facility","inpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KETONES QUALITATIVE","42100001","CDM","301","RC","82009","HCPCS",,,"facility","outpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KETONES QUANTITATIVE","42100002","CDM","301","RC","82010","HCPCS",,,"facility","inpatient",,,,"245","245",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KETONES QUANTITATIVE","42100002","CDM","301","RC","82010","HCPCS",,,"facility","outpatient",,,,"245","245",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALBUMIN","42100006","CDM","301","RC","82040","HCPCS",,,"facility","inpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALBUMIN","42100006","CDM","301","RC","82040","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALBUMIN OTHER SOURCE QN EA","42100007","CDM","301","RC","82042","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALBUMIN OTHER SOURCE QN EA","42100007","CDM","301","RC","82042","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MICROALBUMIN URINE 24HR","42100009","CDM","301","RC","82043","HCPCS",,,"facility","inpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MICROALBUMIN URINE 24HR","42100009","CDM","301","RC","82043","HCPCS",,,"facility","outpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MICROALBUMIN URINE RANDOM","42100010","CDM","301","RC","82043","HCPCS",,,"facility","inpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MICROALBUMIN URINE RANDOM","42100010","CDM","301","RC","82043","HCPCS",,,"facility","outpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALCOHOLS BLOOD","42100012","CDM","301","RC","82077","HCPCS",,,"facility","inpatient",,,,"271","271",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALCOHOLS BLOOD","42100012","CDM","301","RC","82077","HCPCS",,,"facility","outpatient",,,,"271","271",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALCOHOLS URINE","42100013","CDM","301","RC","80307","HCPCS",,,"facility","inpatient",,,,"781","781",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALCOHOLS URINE","42100013","CDM","301","RC","80307","HCPCS",,,"facility","outpatient",,,,"781","781",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALPHA 1 ANTITRYPSIN PHENOTYPE","42100021","CDM","301","RC","82104","HCPCS",,,"facility","inpatient",,,,"100","100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALPHA 1 ANTITRYPSIN PHENOTYPE","42100021","CDM","301","RC","82104","HCPCS",,,"facility","outpatient",,,,"100","100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFP TUMOR MARKER","42100023","CDM","301","RC","82105","HCPCS",,,"facility","inpatient",,,,"170","170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFP TUMOR MARKER","42100023","CDM","301","RC","82105","HCPCS",,,"facility","outpatient",,,,"170","170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMMONIA","42100036","CDM","301","RC","82140","HCPCS",,,"facility","inpatient",,,,"411","411",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMMONIA","42100036","CDM","301","RC","82140","HCPCS",,,"facility","outpatient",,,,"411","411",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMYLASE","42100040","CDM","301","RC","82150","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMYLASE","42100040","CDM","301","RC","82150","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMYLASE FLUID","42100041","CDM","301","RC","82150","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMYLASE FLUID","42100041","CDM","301","RC","82150","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMYLASE URINE RANDOM","42100043","CDM","301","RC","82150","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMYLASE URINE RANDOM","42100043","CDM","301","RC","82150","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMYLASE URINE TIMED","42100044","CDM","301","RC","82150","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AMYLASE URINE TIMED","42100044","CDM","301","RC","82150","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BETA2 MICROGLOBULIN","42100059","CDM","301","RC","82232","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BETA2 MICROGLOBULIN","42100059","CDM","301","RC","82232","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIRUBIN NEONATAL","42100063","CDM","301","RC","82247","HCPCS",,,"facility","inpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIRUBIN NEONATAL","42100063","CDM","301","RC","82247","HCPCS",,,"facility","outpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIRUBIN TOTAL","42100064","CDM","301","RC","82247","HCPCS",,,"facility","inpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIRUBIN TOTAL","42100064","CDM","301","RC","82247","HCPCS",,,"facility","outpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIRUBIN DIRECT","42100065","CDM","301","RC","82248","HCPCS",,,"facility","inpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BILIRUBIN DIRECT","42100065","CDM","301","RC","82248","HCPCS",,,"facility","outpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCCULT BLOOD QUALITATIVE","42100067","CDM","301","RC","82271","HCPCS",,,"facility","inpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCCULT BLOOD QUALITATIVE","42100067","CDM","301","RC","82271","HCPCS",,,"facility","outpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VITAMIN D 25HYDROXY","42100070","CDM","301","RC","82306","HCPCS",,,"facility","inpatient",,,,"277","277",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VITAMIN D 25HYDROXY","42100070","CDM","301","RC","82306","HCPCS",,,"facility","outpatient",,,,"277","277",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM","42100073","CDM","301","RC","82310","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM","42100073","CDM","301","RC","82310","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM FLUID","42100074","CDM","301","RC","82310","HCPCS",,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM FLUID","42100074","CDM","301","RC","82310","HCPCS",,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM IONIZED","42100075","CDM","301","RC","82330","HCPCS",,,"facility","inpatient",,,,"218","218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM IONIZED","42100075","CDM","301","RC","82330","HCPCS",,,"facility","outpatient",,,,"218","218",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM URINE 24HR","42100076","CDM","301","RC","82340","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM URINE 24HR","42100076","CDM","301","RC","82340","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM URINE RANDOM","42100077","CDM","301","RC","82340","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCIUM URINE RANDOM","42100077","CDM","301","RC","82340","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCULUS ANALYSIS XRAY DIFFRACTION","42100082","CDM","301","RC","82370","HCPCS",,,"facility","inpatient",,,,"99","99",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CALCULUS ANALYSIS XRAY DIFFRACTION","42100082","CDM","301","RC","82370","HCPCS",,,"facility","outpatient",,,,"99","99",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CO2 (BICARBONATE)","42100084","CDM","301","RC","82374","HCPCS",,,"facility","inpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CO2 (BICARBONATE)","42100084","CDM","301","RC","82374","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARBON MONOXIDE","42100085","CDM","301","RC","82375","HCPCS",,,"facility","inpatient",,,,"270","270",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARBON MONOXIDE","42100085","CDM","301","RC","82375","HCPCS",,,"facility","outpatient",,,,"270","270",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CEA","42100086","CDM","301","RC","82378","HCPCS",,,"facility","inpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CEA","42100086","CDM","301","RC","82378","HCPCS",,,"facility","outpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CERULOPLASMIN","42100094","CDM","301","RC","82390","HCPCS",,,"facility","inpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CERULOPLASMIN","42100094","CDM","301","RC","82390","HCPCS",,,"facility","outpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE","42100096","CDM","301","RC","82435","HCPCS",,,"facility","inpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE","42100096","CDM","301","RC","82435","HCPCS",,,"facility","outpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE URINE","42100097","CDM","301","RC","82436","HCPCS",,,"facility","inpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE URINE","42100097","CDM","301","RC","82436","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE URINE 24HR","42100098","CDM","301","RC","82436","HCPCS",,,"facility","inpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE URINE 24HR","42100098","CDM","301","RC","82436","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE URINE TIMED","42100099","CDM","301","RC","82436","HCPCS",,,"facility","inpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE URINE TIMED","42100099","CDM","301","RC","82436","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE FLUID","42100100","CDM","301","RC","82438","HCPCS",,,"facility","inpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE FLUID","42100100","CDM","301","RC","82438","HCPCS",,,"facility","outpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE SWEAT","42100102","CDM","301","RC","82438","HCPCS",,,"facility","inpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLORIDE SWEAT","42100102","CDM","301","RC","82438","HCPCS",,,"facility","outpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHOLESTEROL","42100103","CDM","301","RC","82465","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHOLESTEROL","42100103","CDM","301","RC","82465","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHOLESTEROL FLUID","42100104","CDM","301","RC","82465","HCPCS",,,"facility","inpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHOLESTEROL FLUID","42100104","CDM","301","RC","82465","HCPCS",,,"facility","outpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORTISOL TOTAL","42100126","CDM","301","RC","82533","HCPCS",,,"facility","inpatient",,,,"283","283",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CORTISOL TOTAL","42100126","CDM","301","RC","82533","HCPCS",,,"facility","outpatient",,,,"283","283",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CK TOTAL","42100131","CDM","301","RC","82550","HCPCS",,,"facility","inpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CK TOTAL","42100131","CDM","301","RC","82550","HCPCS",,,"facility","outpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CK MB FRACTION","42100133","CDM","301","RC","82553","HCPCS",,,"facility","inpatient",,,,"401","401",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CK MB FRACTION","42100133","CDM","301","RC","82553","HCPCS",,,"facility","outpatient",,,,"401","401",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE","42100134","CDM","301","RC","82565","HCPCS",,,"facility","inpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE","42100134","CDM","301","RC","82565","HCPCS",,,"facility","outpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE FLUID","42100135","CDM","301","RC","82570","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE FLUID","42100135","CDM","301","RC","82570","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE URINE RANDOM","42100137","CDM","301","RC","82570","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE URINE RANDOM","42100137","CDM","301","RC","82570","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE URINE TIMED","42100138","CDM","301","RC","82570","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE URINE TIMED","42100138","CDM","301","RC","82570","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE CLEARANCE","42100139","CDM","301","RC","82575","HCPCS",,,"facility","inpatient",,,,"239","239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CREATININE CLEARANCE","42100139","CDM","301","RC","82575","HCPCS",,,"facility","outpatient",,,,"239","239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYOFIBRINOGEN","42100140","CDM","301","RC","82585","HCPCS",,,"facility","inpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYOFIBRINOGEN","42100140","CDM","301","RC","82585","HCPCS",,,"facility","outpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYOGLOBULIN QUALITATIVE OR SEMI QUANTITATIVE","42100141","CDM","301","RC","82595","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYOGLOBULIN QUALITATIVE OR SEMI QUANTITATIVE","42100141","CDM","301","RC","82595","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VITAMIN B12","42100143","CDM","301","RC","82607","HCPCS",,,"facility","inpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VITAMIN B12","42100143","CDM","301","RC","82607","HCPCS",,,"facility","outpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DHEA SULFATE","42100146","CDM","301","RC","82627","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DHEA SULFATE","42100146","CDM","301","RC","82627","HCPCS",,,"facility","outpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF TOTAL ESTRADIOL","42100158","CDM","301","RC","82670","HCPCS",,,"facility","inpatient",,,,"272","272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF TOTAL ESTRADIOL","42100158","CDM","301","RC","82670","HCPCS",,,"facility","outpatient",,,,"272","272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAT STOOL QUALITATIVE","42100164","CDM","301","RC","82705","HCPCS",,,"facility","inpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAT STOOL QUALITATIVE","42100164","CDM","301","RC","82705","HCPCS",,,"facility","outpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAT STOOL QUANTITATIVE","42100165","CDM","301","RC","82710","HCPCS",,,"facility","inpatient",,,,"324","324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAT STOOL QUANTITATIVE","42100165","CDM","301","RC","82710","HCPCS",,,"facility","outpatient",,,,"324","324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FERRITIN","42100168","CDM","301","RC","82728","HCPCS",,,"facility","inpatient",,,,"256","256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FERRITIN","42100168","CDM","301","RC","82728","HCPCS",,,"facility","outpatient",,,,"256","256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FETAL FIBRONECTIN","42100169","CDM","301","RC","82731","HCPCS",,,"facility","inpatient",,,,"1161","1161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FETAL FIBRONECTIN","42100169","CDM","301","RC","82731","HCPCS",,,"facility","outpatient",,,,"1161","1161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FOLATE","42100170","CDM","301","RC","82746","HCPCS",,,"facility","inpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FOLATE","42100170","CDM","301","RC","82746","HCPCS",,,"facility","outpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FOLATE RBC","42100171","CDM","301","RC","82747","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FOLATE RBC","42100171","CDM","301","RC","82747","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IGA","42100173","CDM","301","RC","82784","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IGA","42100173","CDM","301","RC","82784","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IGG","42100176","CDM","301","RC","82784","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IGG","42100176","CDM","301","RC","82784","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IGM","42100178","CDM","301","RC","82784","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IGM","42100178","CDM","301","RC","82784","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IGE","42100180","CDM","301","RC","82785","HCPCS",,,"facility","inpatient",,,,"170","170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IGE","42100180","CDM","301","RC","82785","HCPCS",,,"facility","outpatient",,,,"170","170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS ARTERIAL","42100183","CDM","301","RC","82803","HCPCS",,,"facility","inpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS ARTERIAL","42100183","CDM","301","RC","82803","HCPCS",,,"facility","outpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS CAPILLARY","42100184","CDM","301","RC","82803","HCPCS",,,"facility","inpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS CAPILLARY","42100184","CDM","301","RC","82803","HCPCS",,,"facility","outpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS CORD ARTERIAL","42100185","CDM","301","RC","82803","HCPCS",,,"facility","inpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS CORD ARTERIAL","42100185","CDM","301","RC","82803","HCPCS",,,"facility","outpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS CORD VENOUS","42100186","CDM","301","RC","82803","HCPCS",,,"facility","inpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS CORD VENOUS","42100186","CDM","301","RC","82803","HCPCS",,,"facility","outpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS VENOUS","42100187","CDM","301","RC","82803","HCPCS",,,"facility","inpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GAS VENOUS","42100187","CDM","301","RC","82803","HCPCS",,,"facility","outpatient",,,,"802","802",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GASES W/02 SATURATION","42100188","CDM","301","RC","82805","HCPCS",,,"facility","inpatient",,,,"914","914",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD GASES W/02 SATURATION","42100188","CDM","301","RC","82805","HCPCS",,,"facility","outpatient",,,,"914","914",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG O2 SATURATION ARTERIAL","42100189","CDM","301","RC","82810","HCPCS",,,"facility","inpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG O2 SATURATION ARTERIAL","42100189","CDM","301","RC","82810","HCPCS",,,"facility","outpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG O2 SATURATION VENOUS","42100190","CDM","301","RC","82810","HCPCS",,,"facility","inpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG O2 SATURATION VENOUS","42100190","CDM","301","RC","82810","HCPCS",,,"facility","outpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCAGON","42100192","CDM","301","RC","82943","HCPCS",,,"facility","inpatient",,,,"298","298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCAGON","42100192","CDM","301","RC","82943","HCPCS",,,"facility","outpatient",,,,"298","298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE CSF","42100193","CDM","301","RC","82945","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE CSF","42100193","CDM","301","RC","82945","HCPCS",,,"facility","outpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE FLUID","42100194","CDM","301","RC","82945","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE FLUID","42100194","CDM","301","RC","82945","HCPCS",,,"facility","outpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE URINE QUANTITATIVE","42100195","CDM","301","RC","82945","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE URINE QUANTITATIVE","42100195","CDM","301","RC","82945","HCPCS",,,"facility","outpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE","42100196","CDM","301","RC","82947","HCPCS",,,"facility","inpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE","42100196","CDM","301","RC","82947","HCPCS",,,"facility","outpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE 1HR PP","42100197","CDM","301","RC","82950","HCPCS",,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE 1HR PP","42100197","CDM","301","RC","82950","HCPCS",,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE 2HR PP","42100198","CDM","301","RC","82950","HCPCS",,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE 2HR PP","42100198","CDM","301","RC","82950","HCPCS",,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE POST GLUCOSE DOSE","42100199","CDM","301","RC","82950","HCPCS",,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE POST GLUCOSE DOSE","42100199","CDM","301","RC","82950","HCPCS",,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE PRENATAL 50 GRAM SCREEN","42100200","CDM","301","RC","82950","HCPCS",,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE PRENATAL 50 GRAM SCREEN","42100200","CDM","301","RC","82950","HCPCS",,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE TOLERANCE FIRST 3 SPECIMENS","42100201","CDM","301","RC","82951","HCPCS",,,"facility","inpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE TOLERANCE FIRST 3 SPECIMENS","42100201","CDM","301","RC","82951","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE TOLERANCE EA ADDL SPECIMEN","42100202","CDM","301","RC","82952","HCPCS",,,"facility","inpatient",,,,"59","59",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLUCOSE TOLERANCE EA ADDL SPECIMEN","42100202","CDM","301","RC","82952","HCPCS",,,"facility","outpatient",,,,"59","59",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GGT","42100206","CDM","301","RC","82977","HCPCS",,,"facility","inpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GGT","42100206","CDM","301","RC","82977","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FSH","42100208","CDM","301","RC","83001","HCPCS",,,"facility","inpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FSH","42100208","CDM","301","RC","83001","HCPCS",,,"facility","outpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LH","42100210","CDM","301","RC","83002","HCPCS",,,"facility","inpatient",,,,"327","327",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LH","42100210","CDM","301","RC","83002","HCPCS",,,"facility","outpatient",,,,"327","327",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HAPTOGLOBIN QUANTITATIVE","42100213","CDM","301","RC","83010","HCPCS",,,"facility","inpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HAPTOGLOBIN QUANTITATIVE","42100213","CDM","301","RC","83010","HCPCS",,,"facility","outpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOGLOBIN F (APT)","42100220","CDM","301","RC","83033","HCPCS",,,"facility","inpatient",,,,"216","216",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOGLOBIN F (APT)","42100220","CDM","301","RC","83033","HCPCS",,,"facility","outpatient",,,,"216","216",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOGLOBIN GLYCOSYLATED A1C","42100221","CDM","301","RC","83036","HCPCS",,,"facility","inpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOGLOBIN GLYCOSYLATED A1C","42100221","CDM","301","RC","83036","HCPCS",,,"facility","outpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG METHEMOGLOBIN QUANTITATIVE","42100222","CDM","301","RC","83050","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG METHEMOGLOBIN QUANTITATIVE","42100222","CDM","301","RC","83050","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOGLOBIN PLASMA","42100223","CDM","301","RC","83051","HCPCS",,,"facility","inpatient",,,,"51","51",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOGLOBIN PLASMA","42100223","CDM","301","RC","83051","HCPCS",,,"facility","outpatient",,,,"51","51",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HOMOCYSTINE","42100227","CDM","301","RC","83090","HCPCS",,,"facility","inpatient",,,,"318","318",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HOMOCYSTINE","42100227","CDM","301","RC","83090","HCPCS",,,"facility","outpatient",,,,"318","318",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOASSAY ANALYTE QUANTITATIVE","42100245","CDM","301","RC","83519","HCPCS",,,"facility","inpatient",,,,"347","347",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOASSAY ANALYTE QUANTITATIVE","42100245","CDM","301","RC","83519","HCPCS",,,"facility","outpatient",,,,"347","347",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSULIN","42100277","CDM","301","RC","83525","HCPCS",,,"facility","inpatient",,,,"134","134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSULIN","42100277","CDM","301","RC","83525","HCPCS",,,"facility","outpatient",,,,"134","134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRON","42100279","CDM","301","RC","83540","HCPCS",,,"facility","inpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRON","42100279","CDM","301","RC","83540","HCPCS",,,"facility","outpatient",,,,"140","140",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRON BINDING CAPACITY","42100282","CDM","301","RC","83550","HCPCS",,,"facility","inpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRON BINDING CAPACITY","42100282","CDM","301","RC","83550","HCPCS",,,"facility","outpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTIC ACID CSF","42100285","CDM","301","RC","83605","HCPCS",,,"facility","inpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTIC ACID CSF","42100285","CDM","301","RC","83605","HCPCS",,,"facility","outpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTIC ACID PLASMA","42100287","CDM","301","RC","83605","HCPCS",,,"facility","inpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTIC ACID PLASMA","42100287","CDM","301","RC","83605","HCPCS",,,"facility","outpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LDH","42100288","CDM","301","RC","83615","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LDH","42100288","CDM","301","RC","83615","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LDH CSF","42100289","CDM","301","RC","83615","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LDH CSF","42100289","CDM","301","RC","83615","HCPCS",,,"facility","outpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LDH FLUID","42100290","CDM","301","RC","83615","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LDH FLUID","42100290","CDM","301","RC","83615","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LAMELLAR BODY DENSITY","42100299","CDM","301","RC","83664","HCPCS",,,"facility","inpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LAMELLAR BODY DENSITY","42100299","CDM","301","RC","83664","HCPCS",,,"facility","outpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIPASE","42100301","CDM","301","RC","83690","HCPCS",,,"facility","inpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIPASE","42100301","CDM","301","RC","83690","HCPCS",,,"facility","outpatient",,,,"257","257",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HDL CHOLESTEROL","42100305","CDM","301","RC","83718","HCPCS",,,"facility","inpatient",,,,"136","136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HDL CHOLESTEROL","42100305","CDM","301","RC","83718","HCPCS",,,"facility","outpatient",,,,"136","136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LDL BY DIRECT MEASURE","42100306","CDM","301","RC","83721","HCPCS",,,"facility","inpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LDL BY DIRECT MEASURE","42100306","CDM","301","RC","83721","HCPCS",,,"facility","outpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MAGNESIUM","42100307","CDM","301","RC","83735","HCPCS",,,"facility","inpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MAGNESIUM","42100307","CDM","301","RC","83735","HCPCS",,,"facility","outpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MAGNESIUM URINE","42100309","CDM","301","RC","83735","HCPCS",,,"facility","inpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MAGNESIUM URINE","42100309","CDM","301","RC","83735","HCPCS",,,"facility","outpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MAGNESIUM URINE TIMED","42100311","CDM","301","RC","83735","HCPCS",,,"facility","inpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MAGNESIUM URINE TIMED","42100311","CDM","301","RC","83735","HCPCS",,,"facility","outpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MASS SPECT/TANDEM QUANTITATIVE NES","42100314","CDM","301","RC","83789","HCPCS",,,"facility","inpatient",,,,"134","134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MASS SPECT/TANDEM QUANTITATIVE NES","42100314","CDM","301","RC","83789","HCPCS",,,"facility","outpatient",,,,"134","134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NATRIURETIC PEPTIDE","42100325","CDM","301","RC","83880","HCPCS",,,"facility","inpatient",,,,"601","601",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NATRIURETIC PEPTIDE","42100325","CDM","301","RC","83880","HCPCS",,,"facility","outpatient",,,,"601","601",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OSMOLALITY SERUM","42100358","CDM","301","RC","83930","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OSMOLALITY SERUM","42100358","CDM","301","RC","83930","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OSMOLALITY URINE","42100359","CDM","301","RC","83935","HCPCS",,,"facility","inpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OSMOLALITY URINE","42100359","CDM","301","RC","83935","HCPCS",,,"facility","outpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PTH","42100364","CDM","301","RC","83970","HCPCS",,,"facility","inpatient",,,,"400","400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PTH","42100364","CDM","301","RC","83970","HCPCS",,,"facility","outpatient",,,,"400","400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PH FLUID","42100367","CDM","301","RC","83986","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PH FLUID","42100367","CDM","301","RC","83986","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHENYLALANINE BLOOD","42100370","CDM","301","RC","84030","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHENYLALANINE BLOOD","42100370","CDM","301","RC","84030","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALKALINE PHOSPHATASE","42100373","CDM","301","RC","84075","HCPCS",,,"facility","inpatient",,,,"97","97",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALKALINE PHOSPHATASE","42100373","CDM","301","RC","84075","HCPCS",,,"facility","outpatient",,,,"97","97",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHOSPHORUS (PO4)","42100376","CDM","301","RC","84100","HCPCS",,,"facility","inpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHOSPHORUS (PO4)","42100376","CDM","301","RC","84100","HCPCS",,,"facility","outpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHOSPHOROUS URINE RANDOM","42100377","CDM","301","RC","84105","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHOSPHOROUS URINE RANDOM","42100377","CDM","301","RC","84105","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHOSPHORUS URINE TIMED","42100379","CDM","301","RC","84105","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHOSPHORUS URINE TIMED","42100379","CDM","301","RC","84105","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POTASSIUM","42100385","CDM","301","RC","84132","HCPCS",,,"facility","inpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POTASSIUM","42100385","CDM","301","RC","84132","HCPCS",,,"facility","outpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POTASSIUM FLUID","42100386","CDM","301","RC","84132","HCPCS",,,"facility","inpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POTASSIUM URINE RANDOM","42100388","CDM","301","RC","84133","HCPCS",,,"facility","inpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POTASSIUM URINE RANDOM","42100388","CDM","301","RC","84133","HCPCS",,,"facility","outpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POTASSIUM URINE TIMED","42100389","CDM","301","RC","84133","HCPCS",,,"facility","inpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POTASSIUM URINE TIMED","42100389","CDM","301","RC","84133","HCPCS",,,"facility","outpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PREALBUMIN","42100390","CDM","301","RC","84134","HCPCS",,,"facility","inpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PREALBUMIN","42100390","CDM","301","RC","84134","HCPCS",,,"facility","outpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROGESTERONE","42100393","CDM","301","RC","84144","HCPCS",,,"facility","inpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROGESTERONE","42100393","CDM","301","RC","84144","HCPCS",,,"facility","outpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROLACTIN","42100394","CDM","301","RC","84146","HCPCS",,,"facility","inpatient",,,,"262","262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROLACTIN","42100394","CDM","301","RC","84146","HCPCS",,,"facility","outpatient",,,,"262","262",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSA TOTAL DIAGNOSTIC","42100396","CDM","301","RC","84153","HCPCS",,,"facility","inpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSA TOTAL DIAGNOSTIC","42100396","CDM","301","RC","84153","HCPCS",,,"facility","outpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSA FREE","42100397","CDM","301","RC","84154","HCPCS",,,"facility","inpatient",,,,"252","252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSA FREE","42100397","CDM","301","RC","84154","HCPCS",,,"facility","outpatient",,,,"252","252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN TOTAL BLOOD","42100398","CDM","301","RC","84155","HCPCS",,,"facility","inpatient",,,,"56","56",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN TOTAL BLOOD","42100398","CDM","301","RC","84155","HCPCS",,,"facility","outpatient",,,,"56","56",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN URINE QUANTITATIVE RANDOM","42100400","CDM","301","RC","84156","HCPCS",,,"facility","inpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN URINE QUANTITATIVE RANDOM","42100400","CDM","301","RC","84156","HCPCS",,,"facility","outpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN URINE QUANTITATIVE TIMED","42100401","CDM","301","RC","84156","HCPCS",,,"facility","inpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN URINE QUANTITATIVE TIMED","42100401","CDM","301","RC","84156","HCPCS",,,"facility","outpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN TOTAL CSF","42100402","CDM","301","RC","84157","HCPCS",,,"facility","inpatient",,,,"233","233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN TOTAL CSF","42100402","CDM","301","RC","84157","HCPCS",,,"facility","outpatient",,,,"233","233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN TOTAL FLUID","42100403","CDM","301","RC","84157","HCPCS",,,"facility","inpatient",,,,"233","233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN TOTAL FLUID","42100403","CDM","301","RC","84157","HCPCS",,,"facility","outpatient",,,,"233","233",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN ELECTROPHORESIS SERUM","42100404","CDM","301","RC","84165","HCPCS",,,"facility","inpatient",,,,"67","67",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN ELECTROPHORESIS SERUM","42100404","CDM","301","RC","84165","HCPCS",,,"facility","outpatient",,,,"67","67",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN ELECTROPHORETIC FRACTIONATION/QUANT","42100406","CDM","301","RC","84166","HCPCS",,,"facility","inpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTEIN ELECTROPHORETIC FRACTIONATION/QUANT","42100406","CDM","301","RC","84166","HCPCS",,,"facility","outpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RECEPTOR ASSAY ESTROGEN","42100417","CDM","301","RC","84233","HCPCS",,,"facility","inpatient",,,,"659","659",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RECEPTOR ASSAY ESTROGEN","42100417","CDM","301","RC","84233","HCPCS",,,"facility","outpatient",,,,"659","659",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RECEPTOR ASSAY PROGESTERONE","42100418","CDM","301","RC","84234","HCPCS",,,"facility","inpatient",,,,"349","349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RECEPTOR ASSAY PROGESTERONE","42100418","CDM","301","RC","84234","HCPCS",,,"facility","outpatient",,,,"349","349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEX HORMONE BINDING GLOBULIN","42100429","CDM","301","RC","84270","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEX HORMONE BINDING GLOBULIN","42100429","CDM","301","RC","84270","HCPCS",,,"facility","outpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SODIUM","42100431","CDM","301","RC","84295","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SODIUM","42100431","CDM","301","RC","84295","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SODIUM URINE RANDOM","42100433","CDM","301","RC","84300","HCPCS",,,"facility","inpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SODIUM URINE RANDOM","42100433","CDM","301","RC","84300","HCPCS",,,"facility","outpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SODIUM URINE TIMED","42100434","CDM","301","RC","84300","HCPCS",,,"facility","inpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SODIUM URINE TIMED","42100434","CDM","301","RC","84300","HCPCS",,,"facility","outpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SODIUM FLUID","42100435","CDM","301","RC","84302","HCPCS",,,"facility","inpatient",,,,"42","42",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SODIUM FLUID","42100435","CDM","301","RC","84302","HCPCS",,,"facility","outpatient",,,,"42","42",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SOMATOMEDIN C","42100437","CDM","301","RC","84305","HCPCS",,,"facility","inpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SOMATOMEDIN C","42100437","CDM","301","RC","84305","HCPCS",,,"facility","outpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIFIC GRAVITY FLUID","42100441","CDM","301","RC","84315","HCPCS",,,"facility","inpatient",,,,"53","53",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIFIC GRAVITY FLUID","42100441","CDM","301","RC","84315","HCPCS",,,"facility","outpatient",,,,"53","53",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUGARS QUALITATIVE EA SPECIMEN","42100442","CDM","301","RC","84376","HCPCS",,,"facility","inpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUGARS QUALITATIVE EA SPECIMEN","42100442","CDM","301","RC","84376","HCPCS",,,"facility","outpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TESTOSTERONE TOTAL","42100445","CDM","301","RC","84403","HCPCS",,,"facility","inpatient",,,,"136","136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TESTOSTERONE TOTAL","42100445","CDM","301","RC","84403","HCPCS",,,"facility","outpatient",,,,"136","136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THYROGLOBULIN","42100449","CDM","301","RC","84432","HCPCS",,,"facility","inpatient",,,,"166","166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THYROGLOBULIN","42100449","CDM","301","RC","84432","HCPCS",,,"facility","outpatient",,,,"166","166",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THYROXINE (T4)","42100450","CDM","301","RC","84436","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THYROXINE (T4)","42100450","CDM","301","RC","84436","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FREE T4","42100452","CDM","301","RC","84439","HCPCS",,,"facility","inpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FREE T4","42100452","CDM","301","RC","84439","HCPCS",,,"facility","outpatient",,,,"231","231",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TSH","42100454","CDM","301","RC","84443","HCPCS",,,"facility","inpatient",,,,"313","313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TSH","42100454","CDM","301","RC","84443","HCPCS",,,"facility","outpatient",,,,"313","313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AST (SGOT)","42100457","CDM","301","RC","84450","HCPCS",,,"facility","inpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AST (SGOT)","42100457","CDM","301","RC","84450","HCPCS",,,"facility","outpatient",,,,"114","114",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALT (SGPT)","42100458","CDM","301","RC","84460","HCPCS",,,"facility","inpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALT (SGPT)","42100458","CDM","301","RC","84460","HCPCS",,,"facility","outpatient",,,,"113","113",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSFERRIN","42100459","CDM","301","RC","84466","HCPCS",,,"facility","inpatient",,,,"198","198",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSFERRIN","42100459","CDM","301","RC","84466","HCPCS",,,"facility","outpatient",,,,"198","198",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRIGLYCERIDE","42100460","CDM","301","RC","84478","HCPCS",,,"facility","inpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRIGLYCERIDE","42100460","CDM","301","RC","84478","HCPCS",,,"facility","outpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRIGLYCERIDE BODY FLUID","42100461","CDM","301","RC","84478","HCPCS",,,"facility","inpatient",,,,"149","149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRIGLYCERIDE BODY FLUID","42100461","CDM","301","RC","84478","HCPCS",,,"facility","outpatient",,,,"149","149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG T3 UPTAKE","42100462","CDM","301","RC","84479","HCPCS",,,"facility","inpatient",,,,"84","84",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG T3 UPTAKE","42100462","CDM","301","RC","84479","HCPCS",,,"facility","outpatient",,,,"84","84",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG T3 TOTAL","42100463","CDM","301","RC","84480","HCPCS",,,"facility","inpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG T3 TOTAL","42100463","CDM","301","RC","84480","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG T3 FREE","42100464","CDM","301","RC","84481","HCPCS",,,"facility","inpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG T3 FREE","42100464","CDM","301","RC","84481","HCPCS",,,"facility","outpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF TROPONIN QUANT","42100466","CDM","301","RC","84484","HCPCS",,,"facility","inpatient",,,,"492","492",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF TROPONIN QUANT","42100466","CDM","301","RC","84484","HCPCS",,,"facility","outpatient",,,,"492","492",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN QUANTITATIVE","42100468","CDM","301","RC","84520","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN QUANTITATIVE","42100468","CDM","301","RC","84520","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN URINE 24HR","42100469","CDM","301","RC","84540","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN URINE 24HR","42100469","CDM","301","RC","84540","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN URINE RANDOM","42100470","CDM","301","RC","84540","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN URINE RANDOM","42100470","CDM","301","RC","84540","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN URINE TIMED","42100471","CDM","301","RC","84540","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN URINE TIMED","42100471","CDM","301","RC","84540","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA CLEARANCE","42100472","CDM","301","RC","84545","HCPCS",,,"facility","inpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA CLEARANCE","42100472","CDM","301","RC","84545","HCPCS",,,"facility","outpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID","42100473","CDM","301","RC","84550","HCPCS",,,"facility","inpatient",,,,"134","134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID","42100473","CDM","301","RC","84550","HCPCS",,,"facility","outpatient",,,,"134","134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID FLUID","42100474","CDM","301","RC","84560","HCPCS",,,"facility","inpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID FLUID","42100474","CDM","301","RC","84560","HCPCS",,,"facility","outpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID URINE 24 HR","42100475","CDM","301","RC","84560","HCPCS",,,"facility","inpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID URINE 24 HR","42100475","CDM","301","RC","84560","HCPCS",,,"facility","outpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID URINE RANDOM","42100476","CDM","301","RC","84560","HCPCS",,,"facility","inpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID URINE RANDOM","42100476","CDM","301","RC","84560","HCPCS",,,"facility","outpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID URINE TIMED","42100477","CDM","301","RC","84560","HCPCS",,,"facility","inpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URIC ACID URINE TIMED","42100477","CDM","301","RC","84560","HCPCS",,,"facility","outpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C PEPTIDE","42100496","CDM","301","RC","84681","HCPCS",,,"facility","inpatient",,,,"138","138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C PEPTIDE","42100496","CDM","301","RC","84681","HCPCS",,,"facility","outpatient",,,,"138","138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BETA HCG QUANTITATIVE","42100497","CDM","301","RC","84702","HCPCS",,,"facility","inpatient",,,,"395","395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BETA HCG QUANTITATIVE","42100497","CDM","301","RC","84702","HCPCS",,,"facility","outpatient",,,,"395","395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BETA HCG QUALITATIVE","42100499","CDM","301","RC","84703","HCPCS",,,"facility","inpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BETA HCG QUALITATIVE","42100499","CDM","301","RC","84703","HCPCS",,,"facility","outpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PREGNANCY TEST SERUM QUALITATIVE","42100500","CDM","301","RC","84703","HCPCS",,,"facility","inpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PREGNANCY TEST SERUM QUALITATIVE","42100500","CDM","301","RC","84703","HCPCS",,,"facility","outpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCCULT BLOOD FECES MULTIPLE SPECIMENS SCREENING","42100520","CDM","301","RC","82270","HCPCS",,,"facility","inpatient",,,,"96","96",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCCULT BLOOD FECES MULTIPLE SPECIMENS SCREENING","42100520","CDM","301","RC","82270","HCPCS",,,"facility","outpatient",,,,"96","96",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF LIPOPROTEIN(A)","42100537","CDM","301","RC","83695","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF LIPOPROTEIN(A)","42100537","CDM","301","RC","83695","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FERN TEST","42100540","CDM","300","RC","Q0114","HCPCS",,,"facility","inpatient",,,,"214","214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FERN TEST","42100540","CDM","300","RC","Q0114","HCPCS",,,"facility","outpatient",,,,"210","210",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PH BLOOD","42100543","CDM","301","RC","82800","HCPCS",,,"facility","inpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PH BLOOD","42100543","CDM","301","RC","82800","HCPCS",,,"facility","outpatient",,,,"309","309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRUG SCRN CAFFEINE","42100546","CDM","301","RC","80155","HCPCS",,,"facility","inpatient",,,,"942","942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRUG SCRN CAFFEINE","42100546","CDM","301","RC","80155","HCPCS",,,"facility","outpatient",,,,"942","942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROCALCITONIN (PCT)","42100547","CDM","301","RC","84145","HCPCS",,,"facility","inpatient",,,,"625","625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROCALCITONIN (PCT)","42100547","CDM","301","RC","84145","HCPCS",,,"facility","outpatient",,,,"625","625",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN FLUID","42100569","CDM","301","RC","84520","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UREA NITROGEN FLUID","42100569","CDM","301","RC","84520","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCCULT BLD IA SCRN","42100571","CDM","301","RC","G0328","HCPCS",,,"facility","inpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCCULT BLD IA SCRN","42100571","CDM","301","RC","G0328","HCPCS",,,"facility","outpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PAMG-IC/V QUAL EACH SPECIMEN","42100600","CDM","301","RC","84112","HCPCS",,,"facility","inpatient",,,,"489","489",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PAMG-IC/V QUAL EACH SPECIMEN","42100600","CDM","301","RC","84112","HCPCS",,,"facility","outpatient",,,,"489","489",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MACRO EXAM ARTHROPOD","42100768","CDM","306","RC","87168","HCPCS",,,"facility","inpatient",,,,"216","216",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MACRO EXAM ARTHROPOD","42100768","CDM","306","RC","87168","HCPCS",,,"facility","outpatient",,,,"216","216",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SHIGA LIKE TOXIN EIA","42100770","CDM","306","RC","87427","HCPCS",,,"facility","inpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SHIGA LIKE TOXIN EIA","42100770","CDM","306","RC","87427","HCPCS",,,"facility","outpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RPR NON-TREPNML AB QL","42100824","CDM","302","RC","86592","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RPR NON-TREPNML AB QL","42100824","CDM","302","RC","86592","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTIC ACID BLOOD","42100825","CDM","301","RC","83605","HCPCS",,,"facility","inpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTIC ACID BLOOD","42100825","CDM","301","RC","83605","HCPCS",,,"facility","outpatient",,,,"333","333",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG PATH LVL III","42100831","CDM","312","RC","88304","HCPCS",,,"facility","inpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG PATH LVL III","42100831","CDM","312","RC","88304","HCPCS",,,"facility","outpatient",,,,"222","222",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTO CL BLK 5 CNT/1 KARY","42100832","CDM","312","RC","88305","HCPCS",,,"facility","inpatient",,,,"281","281",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTO CL BLK 5 CNT/1 KARY","42100832","CDM","312","RC","88305","HCPCS",,,"facility","outpatient",,,,"293","293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT OTHER SOURCE AEROBIC","42100834","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT OTHER SOURCE AEROBIC","42100834","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GTT 3HR 1ST 3 SPEC","42100837","CDM","301","RC","82951","HCPCS",,,"facility","inpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GTT 3HR 1ST 3 SPEC","42100837","CDM","301","RC","82951","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I & II TYPING LR","42100840","CDM","301","RC","81370","HCPCS",,,"facility","inpatient",,,,"2307","2307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I & II TYPING LR","42100840","CDM","301","RC","81370","HCPCS",,,"facility","outpatient",,,,"2307","2307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I & II TYPE VERIFY LR","42100841","CDM","301","RC","81371","HCPCS",,,"facility","inpatient",,,,"1537","1537",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I & II TYPE VERIFY LR","42100841","CDM","301","RC","81371","HCPCS",,,"facility","outpatient",,,,"1537","1537",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I TYPING COMPLETE LR","42100842","CDM","301","RC","81372","HCPCS",,,"facility","inpatient",,,,"1164","1164",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I TYPING COMPLETE LR","42100842","CDM","301","RC","81372","HCPCS",,,"facility","outpatient",,,,"1164","1164",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I TYPING 1 LOCUS LR","42100843","CDM","301","RC","81373","HCPCS",,,"facility","inpatient",,,,"373","373",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I TYPING 1 LOCUS LR","42100843","CDM","301","RC","81373","HCPCS",,,"facility","outpatient",,,,"373","373",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I TYPING 1 ANTIGEN LR","42100844","CDM","301","RC","81374","HCPCS",,,"facility","inpatient",,,,"328","328",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA I TYPING 1 ANTIGEN LR","42100844","CDM","301","RC","81374","HCPCS",,,"facility","outpatient",,,,"328","328",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA II TYPING AG EQUIV LR","42100845","CDM","301","RC","81375","HCPCS",,,"facility","inpatient",,,,"1053","1053",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA II TYPING AG EQUIV LR","42100845","CDM","301","RC","81375","HCPCS",,,"facility","outpatient",,,,"1053","1053",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA II TYPING 1 LOCUS LR","42100846","CDM","301","RC","81376","HCPCS",,,"facility","inpatient",,,,"382","382",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA II TYPING 1 LOCUS LR","42100846","CDM","301","RC","81376","HCPCS",,,"facility","outpatient",,,,"382","382",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA II TYPE 1 AG EQUIV LR","42100847","CDM","301","RC","81377","HCPCS",,,"facility","inpatient",,,,"329","329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA II TYPE 1 AG EQUIV LR","42100847","CDM","301","RC","81377","HCPCS",,,"facility","outpatient",,,,"329","329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTOFERRIN FECAL QUALITATIVE","42100848","CDM","301","RC","83630","HCPCS",,,"facility","inpatient",,,,"222","222",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTOFERRIN FECAL QUALITATIVE","42100848","CDM","301","RC","83630","HCPCS",,,"facility","outpatient",,,,"222","222",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GTT 4HR 1ST 3 SPEC","42100850","CDM","301","RC","82951","HCPCS",,,"facility","inpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GTT 4HR 1ST 3 SPEC","42100850","CDM","301","RC","82951","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCC BLD 1-3 SPC NO NPLSM","42100853","CDM","301","RC","82272","HCPCS",,,"facility","inpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCC BLD 1-3 SPC NO NPLSM","42100853","CDM","301","RC","82272","HCPCS",,,"facility","outpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF SERUM POTASSIUM","42100872","CDM","301","RC","84132","HCPCS",,,"facility","inpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASSAY OF SERUM POTASSIUM","42100872","CDM","301","RC","84132","HCPCS",,,"facility","outpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLEEDING TIME TEST","43000000","CDM","305","RC","85002","HCPCS",,,"facility","inpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLEEDING TIME TEST","43000000","CDM","305","RC","85002","HCPCS",,,"facility","outpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELET FUNCTION TEST","43000001","CDM","305","RC","85002","HCPCS",,,"facility","inpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELET FUNCTION TEST","43000001","CDM","305","RC","85002","HCPCS",,,"facility","outpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD SMEAR EXAM W/ MANUAL DIFFERENTIAL","43000003","CDM","305","RC","85007","HCPCS",,,"facility","inpatient",,,,"97","97",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD SMEAR EXAM W/ MANUAL DIFFERENTIAL","43000003","CDM","305","RC","85007","HCPCS",,,"facility","outpatient",,,,"97","97",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD SMEAR EXAM W/O MANUAL DIFFERENTIAL","43000004","CDM","305","RC","85008","HCPCS",,,"facility","inpatient",,,,"64","64",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD SMEAR EXAM W/O MANUAL DIFFERENTIAL","43000004","CDM","305","RC","85008","HCPCS",,,"facility","outpatient",,,,"64","64",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMATOCRIT SPUN","43000006","CDM","305","RC","85013","HCPCS",,,"facility","inpatient",,,,"86","86",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMATOCRIT SPUN","43000006","CDM","305","RC","85013","HCPCS",,,"facility","outpatient",,,,"86","86",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMATOCRIT","43000007","CDM","305","RC","85014","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMATOCRIT","43000007","CDM","305","RC","85014","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOGLOBIN","43000008","CDM","305","RC","85018","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOGLOBIN","43000008","CDM","305","RC","85018","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CBC AUTOMATED W/ AUTOMATED DIFFERENTIAL","43000009","CDM","305","RC","85025","HCPCS",,,"facility","inpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CBC AUTOMATED W/ AUTOMATED DIFFERENTIAL","43000009","CDM","305","RC","85025","HCPCS",,,"facility","outpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CBC AUTOMATED","43000010","CDM","305","RC","85027","HCPCS",,,"facility","inpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CBC AUTOMATED","43000010","CDM","305","RC","85027","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RETICULOCYTE AUTOMATED","43000014","CDM","305","RC","85045","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RETICULOCYTE AUTOMATED","43000014","CDM","305","RC","85045","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WBC COUNT AUTOMATED","43000015","CDM","305","RC","85048","HCPCS",,,"facility","inpatient",,,,"55","55",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WBC COUNT AUTOMATED","43000015","CDM","305","RC","85048","HCPCS",,,"facility","outpatient",,,,"55","55",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELET COUNT AUTOMATED","43000016","CDM","305","RC","85049","HCPCS",,,"facility","inpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELET COUNT AUTOMATED","43000016","CDM","305","RC","85049","HCPCS",,,"facility","outpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTERPRETATION BONE MARROW SMEAR","43000018","CDM","305","RC","85097","HCPCS",,,"facility","inpatient",,,,"672","672",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTERPRETATION BONE MARROW SMEAR","43000018","CDM","305","RC","85097","HCPCS",,,"facility","outpatient",,,,"672","672",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FACTOR XA AB CHROMOGENIC","43000019","CDM","305","RC","85130","HCPCS",,,"facility","inpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FACTOR XA AB CHROMOGENIC","43000019","CDM","305","RC","85130","HCPCS",,,"facility","outpatient",,,,"488","488",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR V LABILE FACTOR","43000022","CDM","305","RC","85220","HCPCS",,,"facility","inpatient",,,,"324","324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR V LABILE FACTOR","43000022","CDM","305","RC","85220","HCPCS",,,"facility","outpatient",,,,"324","324",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR VIII 1 STAGE","43000024","CDM","305","RC","85240","HCPCS",,,"facility","inpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR VIII 1 STAGE","43000024","CDM","305","RC","85240","HCPCS",,,"facility","outpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR IX","43000029","CDM","305","RC","85250","HCPCS",,,"facility","inpatient",,,,"386","386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR IX","43000029","CDM","305","RC","85250","HCPCS",,,"facility","outpatient",,,,"386","386",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR XI","43000031","CDM","305","RC","85270","HCPCS",,,"facility","inpatient",,,,"313","313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR XI","43000031","CDM","305","RC","85270","HCPCS",,,"facility","outpatient",,,,"313","313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR XIII SCREEN SOLUBILITY","43000034","CDM","305","RC","85291","HCPCS",,,"facility","inpatient",,,,"345","345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING FACTOR XIII SCREEN SOLUBILITY","43000034","CDM","305","RC","85291","HCPCS",,,"facility","outpatient",,,,"345","345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTITHROMBIN III ACTIVITY","43000036","CDM","305","RC","85300","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTITHROMBIN III ACTIVITY","43000036","CDM","305","RC","85300","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FACTOR INHIBITOR TEST","43000045","CDM","305","RC","85335","HCPCS",,,"facility","inpatient",,,,"405","405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FACTOR INHIBITOR TEST","43000045","CDM","305","RC","85335","HCPCS",,,"facility","outpatient",,,,"405","405",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ACTIVATED CLOTTING TIME","43000046","CDM","305","RC","85347","HCPCS",,,"facility","inpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ACTIVATED CLOTTING TIME","43000046","CDM","305","RC","85347","HCPCS",,,"facility","outpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FIBRIN DEGRADATION PROD AGGLTNTN SLIDE SEMIQUAN","43000048","CDM","305","RC","85362","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FIBRIN DEGRADATION PROD AGGLTNTN SLIDE SEMIQUAN","43000048","CDM","305","RC","85362","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG D DIMER SEMI QUANTITATIVE/QUALITATIVE","43000050","CDM","305","RC","85378","HCPCS",,,"facility","inpatient",,,,"367","367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG D DIMER SEMI QUANTITATIVE/QUALITATIVE","43000050","CDM","305","RC","85378","HCPCS",,,"facility","outpatient",,,,"367","367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG D DIMER QUANTITATIVE","43000051","CDM","305","RC","85379","HCPCS",,,"facility","inpatient",,,,"370","370",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG D DIMER QUANTITATIVE","43000051","CDM","305","RC","85379","HCPCS",,,"facility","outpatient",,,,"370","370",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FIBRINOGEN ACTIVITY","43000052","CDM","305","RC","85384","HCPCS",,,"facility","inpatient",,,,"320","320",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FIBRINOGEN ACTIVITY","43000052","CDM","305","RC","85384","HCPCS",,,"facility","outpatient",,,,"320","320",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FETAL RBC SMEAR (KLEIHAUER BETKE)","43000058","CDM","305","RC","85460","HCPCS",,,"facility","inpatient",,,,"181","181",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FETAL RBC SMEAR (KLEIHAUER BETKE)","43000058","CDM","305","RC","85460","HCPCS",,,"facility","outpatient",,,,"181","181",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FETAL SCREEN ROSETTE","43000059","CDM","305","RC","85461","HCPCS",,,"facility","inpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FETAL SCREEN ROSETTE","43000059","CDM","305","RC","85461","HCPCS",,,"facility","outpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOLYSIN ACID (HAM'S)","43000060","CDM","305","RC","85475","HCPCS",,,"facility","inpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMOLYSIN ACID (HAM'S)","43000060","CDM","305","RC","85475","HCPCS",,,"facility","outpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPARIN ASSAY","43000061","CDM","305","RC","85520","HCPCS",,,"facility","inpatient",,,,"478","478",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPARIN ASSAY","43000061","CDM","305","RC","85520","HCPCS",,,"facility","outpatient",,,,"478","478",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPARIN NEUTRALIZATION","43000062","CDM","305","RC","85525","HCPCS",,,"facility","inpatient",,,,"23","23",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPARIN NEUTRALIZATION","43000062","CDM","305","RC","85525","HCPCS",,,"facility","outpatient",,,,"23","23",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRON STAIN BLOOD","43000063","CDM","305","RC","85536","HCPCS",,,"facility","inpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRON STAIN BLOOD","43000063","CDM","305","RC","85536","HCPCS",,,"facility","outpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEUKOCYTE ALKALINE PHOSHATASE (LAP)","43000064","CDM","305","RC","85540","HCPCS",,,"facility","inpatient",,,,"14","14",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEUKOCYTE ALKALINE PHOSHATASE (LAP)","43000064","CDM","305","RC","85540","HCPCS",,,"facility","outpatient",,,,"14","14",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELET AGGREGATION EA AGENT","43000066","CDM","305","RC","85576","HCPCS",,,"facility","inpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLATELET AGGREGATION EA AGENT","43000066","CDM","305","RC","85576","HCPCS",,,"facility","outpatient",,,,"292","292",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTHROMBIN TIME","43000070","CDM","305","RC","85610","HCPCS",,,"facility","inpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROTHROMBIN TIME","43000070","CDM","305","RC","85610","HCPCS",,,"facility","outpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPTILASE TEST","43000073","CDM","305","RC","85635","HCPCS",,,"facility","inpatient",,,,"227","227",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPTILASE TEST","43000073","CDM","305","RC","85635","HCPCS",,,"facility","outpatient",,,,"227","227",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEDIMENTATION RATE MANUAL","43000074","CDM","305","RC","85651","HCPCS",,,"facility","inpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEDIMENTATION RATE MANUAL","43000074","CDM","305","RC","85651","HCPCS",,,"facility","outpatient",,,,"148","148",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEDIMENTATION RATE AUTOMATED","43000075","CDM","305","RC","85652","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEDIMENTATION RATE AUTOMATED","43000075","CDM","305","RC","85652","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SICKLE CELL SCREEN","43000076","CDM","305","RC","85660","HCPCS",,,"facility","inpatient",,,,"46","46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SICKLE CELL SCREEN","43000076","CDM","305","RC","85660","HCPCS",,,"facility","outpatient",,,,"46","46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBIN TIME","43000077","CDM","305","RC","85670","HCPCS",,,"facility","inpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THROMBIN TIME","43000077","CDM","305","RC","85670","HCPCS",,,"facility","outpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PTT PLASMA OR WHOLE BLOOD","43000078","CDM","305","RC","85730","HCPCS",,,"facility","inpatient",,,,"236","236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PTT PLASMA OR WHOLE BLOOD","43000078","CDM","305","RC","85730","HCPCS",,,"facility","outpatient",,,,"236","236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEINZ BODY STAIN","43000083","CDM","305","RC","85441","HCPCS",,,"facility","inpatient",,,,"138","138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEINZ BODY STAIN","43000083","CDM","305","RC","85441","HCPCS",,,"facility","outpatient",,,,"138","138",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRUG SCREEN CLASS LIST A","43000089","CDM","301","RC","80307","HCPCS",,,"facility","inpatient",,,,"781","781",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRUG SCREEN CLASS LIST A","43000089","CDM","301","RC","80307","HCPCS",,,"facility","outpatient",,,,"781","781",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING ASSAY WHOLE BLOOD","43000094","CDM","305","RC","85396","HCPCS",,,"facility","inpatient",,,,"463","463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLOTTING ASSAY WHOLE BLOOD","43000094","CDM","305","RC","85396","HCPCS",,,"facility","outpatient",,,,"463","463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FIBRINOLYSINS/COAG SCREEN INTERP&REPORT","43000097","CDM","305","RC","85390","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FIBRINOLYSINS/COAG SCREEN INTERP&REPORT","43000097","CDM","305","RC","85390","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY SCREEN","44000000","CDM","302","RC","86850","HCPCS",,,"facility","inpatient",,,,"255","255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY SCREEN","44000000","CDM","302","RC","86850","HCPCS",,,"facility","outpatient",,,,"255","255",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY SCREEN 2","44000001","CDM","302","RC","86850","HCPCS",,,"facility","inpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY SCREEN 2","44000001","CDM","302","RC","86850","HCPCS",,,"facility","outpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY SCREEN 3","44000002","CDM","302","RC","86850","HCPCS",,,"facility","inpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY SCREEN 3","44000002","CDM","302","RC","86850","HCPCS",,,"facility","outpatient",,,,"242","242",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY ELUTION","44000003","CDM","302","RC","86860","HCPCS",,,"facility","inpatient",,,,"236","236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY ELUTION","44000003","CDM","302","RC","86860","HCPCS",,,"facility","outpatient",,,,"236","236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY ID","44000004","CDM","302","RC","86870","HCPCS",,,"facility","inpatient",,,,"669","669",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY ID","44000004","CDM","302","RC","86870","HCPCS",,,"facility","outpatient",,,,"669","669",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COOMBS DIRECT C3","44000005","CDM","302","RC","86880","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COOMBS DIRECT C3","44000005","CDM","302","RC","86880","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COOMBS DIRECT IGG","44000006","CDM","302","RC","86880","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COOMBS DIRECT IGG","44000006","CDM","302","RC","86880","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COOMBS DIRECT POLYSPECIFIC","44000007","CDM","302","RC","86880","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COOMBS DIRECT POLYSPECIFIC","44000007","CDM","302","RC","86880","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY TITER","44000009","CDM","302","RC","86886","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANTIBODY TITER","44000009","CDM","302","RC","86886","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABO TYPE SEROLOGIC","44000010","CDM","302","RC","86900","HCPCS",,,"facility","inpatient",,,,"205","205",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABO TYPE SEROLOGIC","44000010","CDM","302","RC","86900","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RH TYPE SEROLOGIC","44000011","CDM","302","RC","86901","HCPCS",,,"facility","inpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RH TYPE SEROLOGIC","44000011","CDM","302","RC","86901","HCPCS",,,"facility","outpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLD TYPE SEROLOGIC SCRN ANTGN EA UNIT PT SERUM","44000013","CDM","302","RC","86904","HCPCS",,,"facility","inpatient",,,,"55","55",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLD TYPE SEROLOGIC SCRN ANTGN EA UNIT PT SERUM","44000013","CDM","302","RC","86904","HCPCS",,,"facility","outpatient",,,,"55","55",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC ANTIGENS EA","44000014","CDM","302","RC","86905","HCPCS",,,"facility","inpatient",,,,"193","193",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC ANTIGENS EA","44000014","CDM","302","RC","86905","HCPCS",,,"facility","outpatient",,,,"193","193",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RH PHENOTYPE COMPLETE","44000015","CDM","302","RC","86906","HCPCS",,,"facility","inpatient",,,,"86","86",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RH PHENOTYPE COMPLETE","44000015","CDM","302","RC","86906","HCPCS",,,"facility","outpatient",,,,"86","86",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPATIBILITY TEST IMMEDIATE SPIN","44000016","CDM","302","RC","86920","HCPCS",,,"facility","inpatient",,,,"576","576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPATIBILITY TEST IMMEDIATE SPIN","44000016","CDM","302","RC","86920","HCPCS",,,"facility","outpatient",,,,"576","576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPATIBILITY TEST INCUBATED","44000017","CDM","300","RC","86921","HCPCS",,,"facility","inpatient",,,,"589","589",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPATIBILITY TEST INCUBATED","44000017","CDM","300","RC","86921","HCPCS",,,"facility","outpatient",,,,"589","589",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPATIBILITY TEST ANTIGLOBULIN","44000018","CDM","302","RC","86922","HCPCS",,,"facility","inpatient",,,,"598","598",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPATIBILITY TEST ANTIGLOBULIN","44000018","CDM","302","RC","86922","HCPCS",,,"facility","outpatient",,,,"598","598",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FROZEN BLOOD FREEZING W PREP","44000021","CDM","302","RC","86930","HCPCS",,,"facility","inpatient",,,,"788","788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FROZEN BLOOD FREEZING W PREP","44000021","CDM","302","RC","86930","HCPCS",,,"facility","outpatient",,,,"788","788",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRRADIATION BLOOD PRODUCT EA","44000024","CDM","302","RC","86945","HCPCS",,,"facility","inpatient",,,,"71","71",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRRADIATION BLOOD PRODUCT EA","44000024","CDM","302","RC","86945","HCPCS",,,"facility","outpatient",,,,"71","71",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POOLING BLOOD PRODUCTS","44000026","CDM","302","RC","86965","HCPCS",,,"facility","inpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG POOLING BLOOD PRODUCTS","44000026","CDM","302","RC","86965","HCPCS",,,"facility","outpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC PRETREATMENT CHEMICAL AGENT/DRUG","44000027","CDM","302","RC","86970","HCPCS",,,"facility","inpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC PRETREATMENT CHEMICAL AGENT/DRUG","44000027","CDM","302","RC","86970","HCPCS",,,"facility","outpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC PRETREATMENT ENZYME","44000028","CDM","302","RC","86971","HCPCS",,,"facility","inpatient",,,,"153","153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC PRETREATMENT ENZYME","44000028","CDM","302","RC","86971","HCPCS",,,"facility","outpatient",,,,"153","153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SER PRETREATMENT INCUBATION W/ INHIBITORS","44000032","CDM","302","RC","86977","HCPCS",,,"facility","inpatient",,,,"435","435",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SER PRETREATMENT INCUBATION W/ INHIBITORS","44000032","CDM","302","RC","86977","HCPCS",,,"facility","outpatient",,,,"435","435",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SERUM PRETREATMENT ABSORPTION EA","44000033","CDM","302","RC","86978","HCPCS",,,"facility","inpatient",,,,"137","137",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SERUM PRETREATMENT ABSORPTION EA","44000033","CDM","302","RC","86978","HCPCS",,,"facility","outpatient",,,,"137","137",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPLITTING BLOOD PRODUCTS EA UNIT","44000034","CDM","302","RC","86985","HCPCS",,,"facility","inpatient",,,,"525","525",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPLITTING BLOOD PRODUCTS EA UNIT","44000034","CDM","302","RC","86985","HCPCS",,,"facility","outpatient",,,,"525","525",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THAWING PRODUCT PER UNIT","44000035","CDM","300","RC","86927","HCPCS",,,"facility","inpatient",,,,"362","362",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THAWING PRODUCT PER UNIT","44000035","CDM","300","RC","86927","HCPCS",,,"facility","outpatient",,,,"362","362",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TYPE SEROLOGIC ANTGN DONOR EA","44000036","CDM","302","RC","86902","HCPCS",,,"facility","inpatient",,,,"159","159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TYPE SEROLOGIC ANTGN DONOR EA","44000036","CDM","302","RC","86902","HCPCS",,,"facility","outpatient",,,,"159","159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC L/R CMV NEG IRR PS EA UNIT","44000038","CDM","390","RC","P9058","HCPCS",,,"facility","inpatient",,,,"315","315",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RBC L/R CMV NEG IRR PS EA UNIT","44000038","CDM","390","RC","P9058","HCPCS",,,"facility","outpatient",,,,"315","315",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AB ID 2","44000040","CDM","302","RC","86870","HCPCS",,,"facility","inpatient",,,,"642","642",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AB ID 2","44000040","CDM","302","RC","86870","HCPCS",,,"facility","outpatient",,,,"642","642",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CROSS MATCH ELECTRONIC","44000041","CDM","302","RC","86923","HCPCS",,,"facility","inpatient",,,,"554","554",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CROSS MATCH ELECTRONIC","44000041","CDM","302","RC","86923","HCPCS",,,"facility","outpatient",,,,"554","554",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABO RECHECK UNIT/PATIENT","44000042","CDM","302","RC","86900","HCPCS",,,"facility","inpatient",,,,"205","205",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABO RECHECK UNIT/PATIENT","44000042","CDM","302","RC","86900","HCPCS",,,"facility","outpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TYPING ABO","44000045","CDM","302","RC","86900","HCPCS",,,"facility","inpatient",,,,"205","205",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TYPING ABO","44000045","CDM","302","RC","86900","HCPCS",,,"facility","outpatient",,,,"103","103",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANA (ANTI NUCLEAR AB)","45000030","CDM","302","RC","86038","HCPCS",,,"facility","inpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANA (ANTI NUCLEAR AB)","45000030","CDM","302","RC","86038","HCPCS",,,"facility","outpatient",,,,"91","91",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASO SCREEN","45000034","CDM","302","RC","86063","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ASO SCREEN","45000034","CDM","302","RC","86063","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C REACTIVE PROTEIN","45000035","CDM","302","RC","86140","HCPCS",,,"facility","inpatient",,,,"177","177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C REACTIVE PROTEIN","45000035","CDM","302","RC","86140","HCPCS",,,"facility","outpatient",,,,"177","177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C-REACTIVE PROTEIN HIGH SENSITIVITY","45000036","CDM","302","RC","86141","HCPCS",,,"facility","inpatient",,,,"227","227",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C-REACTIVE PROTEIN HIGH SENSITIVITY","45000036","CDM","302","RC","86141","HCPCS",,,"facility","outpatient",,,,"227","227",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOLIPIN IGA AB","45000039","CDM","302","RC","86147","HCPCS",,,"facility","inpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOLIPIN IGA AB","45000039","CDM","302","RC","86147","HCPCS",,,"facility","outpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOLIPIN IGG AB","45000040","CDM","302","RC","86147","HCPCS",,,"facility","inpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOLIPIN IGG AB","45000040","CDM","302","RC","86147","HCPCS",,,"facility","outpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOLIPIN IGM AB","45000041","CDM","302","RC","86147","HCPCS",,,"facility","inpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOLIPIN IGM AB","45000041","CDM","302","RC","86147","HCPCS",,,"facility","outpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLD AGGLUTININ TITER","45000044","CDM","302","RC","86157","HCPCS",,,"facility","inpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLD AGGLUTININ TITER","45000044","CDM","302","RC","86157","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPLEMENT","45000048","CDM","302","RC","86160","HCPCS",,,"facility","inpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COMPLEMENT","45000048","CDM","302","RC","86160","HCPCS",,,"facility","outpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA 15 3 (27.29)","45000092","CDM","302","RC","86300","HCPCS",,,"facility","inpatient",,,,"192","192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA 15 3 (27.29)","45000092","CDM","302","RC","86300","HCPCS",,,"facility","outpatient",,,,"192","192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA 19 9","45000093","CDM","302","RC","86301","HCPCS",,,"facility","inpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA 19 9","45000093","CDM","302","RC","86301","HCPCS",,,"facility","outpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA 125","45000094","CDM","302","RC","86304","HCPCS",,,"facility","inpatient",,,,"256","256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CA 125","45000094","CDM","302","RC","86304","HCPCS",,,"facility","outpatient",,,,"256","256",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HETEROPHILE AB SCREEN","45000095","CDM","302","RC","86308","HCPCS",,,"facility","inpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HETEROPHILE AB SCREEN","45000095","CDM","302","RC","86308","HCPCS",,,"facility","outpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MONO TEST SCREEN","45000096","CDM","302","RC","86308","HCPCS",,,"facility","inpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MONO TEST SCREEN","45000096","CDM","302","RC","86308","HCPCS",,,"facility","outpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOFIXATION SERUM","45000106","CDM","302","RC","86334","HCPCS",,,"facility","inpatient",,,,"159","159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOFIXATION SERUM","45000106","CDM","302","RC","86334","HCPCS",,,"facility","outpatient",,,,"159","159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOFIXATION URINE","45000107","CDM","302","RC","86335","HCPCS",,,"facility","inpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOFIXATION URINE","45000107","CDM","302","RC","86335","HCPCS",,,"facility","outpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RHEUMATOID FACTOR QUALITATIVE","45000126","CDM","302","RC","86430","HCPCS",,,"facility","inpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RHEUMATOID FACTOR QUALITATIVE","45000126","CDM","302","RC","86430","HCPCS",,,"facility","outpatient",,,,"126","126",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RHEUMATOID FACTOR QUANTITATIVE","45000127","CDM","302","RC","86431","HCPCS",,,"facility","inpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RHEUMATOID FACTOR QUANTITATIVE","45000127","CDM","302","RC","86431","HCPCS",,,"facility","outpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RPR QUALITATIVE","45000128","CDM","302","RC","86592","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RPR QUALITATIVE","45000128","CDM","302","RC","86592","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VDRL CSF QUALITATIVE","45000129","CDM","302","RC","86592","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VDRL CSF QUALITATIVE","45000129","CDM","302","RC","86592","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RPR TITER","45000130","CDM","302","RC","86593","HCPCS",,,"facility","inpatient",,,,"19","19",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RPR TITER","45000130","CDM","302","RC","86593","HCPCS",,,"facility","outpatient",,,,"19","19",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CMV AB","45000164","CDM","302","RC","86644","HCPCS",,,"facility","inpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CMV AB","45000164","CDM","302","RC","86644","HCPCS",,,"facility","outpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CMV AB IGM","45000166","CDM","302","RC","86645","HCPCS",,,"facility","inpatient",,,,"378","378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CMV AB IGM","45000166","CDM","302","RC","86645","HCPCS",,,"facility","outpatient",,,,"378","378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GIARDIA AB","45000193","CDM","302","RC","86674","HCPCS",,,"facility","inpatient",,,,"211","211",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GIARDIA AB","45000193","CDM","302","RC","86674","HCPCS",,,"facility","outpatient",,,,"211","211",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG H PYLORI AB","45000198","CDM","302","RC","86677","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG H PYLORI AB","45000198","CDM","302","RC","86677","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIV 1/HIV 2 AB","45000219","CDM","302","RC","86703","HCPCS",,,"facility","inpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIV 1/HIV 2 AB","45000219","CDM","302","RC","86703","HCPCS",,,"facility","outpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B CORE AB TOTAL","45000220","CDM","302","RC","86704","HCPCS",,,"facility","inpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B CORE AB TOTAL","45000220","CDM","302","RC","86704","HCPCS",,,"facility","outpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B CORE AB IGM","45000221","CDM","302","RC","86705","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B CORE AB IGM","45000221","CDM","302","RC","86705","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B SURFACE AB","45000222","CDM","302","RC","86706","HCPCS",,,"facility","inpatient",,,,"137","137",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B SURFACE AB","45000222","CDM","302","RC","86706","HCPCS",,,"facility","outpatient",,,,"137","137",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS A AB TOTAL","45000224","CDM","302","RC","86708","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS A AB TOTAL","45000224","CDM","302","RC","86708","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS A AB IGM","45000225","CDM","302","RC","86709","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS A AB IGM","45000225","CDM","302","RC","86709","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RUBELLA AB","45000254","CDM","302","RC","86762","HCPCS",,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RUBELLA AB","45000254","CDM","302","RC","86762","HCPCS",,,"facility","outpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RUBEOLA AB","45000258","CDM","302","RC","86765","HCPCS",,,"facility","inpatient",,,,"90","90",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RUBEOLA AB","45000258","CDM","302","RC","86765","HCPCS",,,"facility","outpatient",,,,"90","90",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOXOPLASMA AB IGG","45000262","CDM","302","RC","86777","HCPCS",,,"facility","inpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOXOPLASMA AB IGG","45000262","CDM","302","RC","86777","HCPCS",,,"facility","outpatient",,,,"119","119",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOXOPLASMA AB IGM","45000263","CDM","302","RC","86778","HCPCS",,,"facility","inpatient",,,,"287","287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOXOPLASMA AB IGM","45000263","CDM","302","RC","86778","HCPCS",,,"facility","outpatient",,,,"287","287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MHA TREPONEMA PALLIDUM","45000265","CDM","302","RC","86780","HCPCS",,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MHA TREPONEMA PALLIDUM","45000265","CDM","302","RC","86780","HCPCS",,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VARICELLA ZOSTER AB","45000266","CDM","302","RC","86787","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VARICELLA ZOSTER AB","45000266","CDM","302","RC","86787","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THYROGLOBULIN AB","45000277","CDM","302","RC","86800","HCPCS",,,"facility","inpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THYROGLOBULIN AB","45000277","CDM","302","RC","86800","HCPCS",,,"facility","outpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS C  AB","45000278","CDM","302","RC","86803","HCPCS",,,"facility","inpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS C  AB","45000278","CDM","302","RC","86803","HCPCS",,,"facility","outpatient",,,,"182","182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA TYPE A B OR C MULTIPLE ANTIGENS","45000295","CDM","302","RC","86813","HCPCS",,,"facility","inpatient",,,,"1484","1484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA TYPE A B OR C MULTIPLE ANTIGENS","45000295","CDM","302","RC","86813","HCPCS",,,"facility","outpatient",,,,"1484","1484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA TYPE DR/DQ MULTIPLE ANTIGENS","45000296","CDM","302","RC","86817","HCPCS",,,"facility","inpatient",,,,"1616","1616",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HLA TYPE DR/DQ MULTIPLE ANTIGENS","45000296","CDM","302","RC","86817","HCPCS",,,"facility","outpatient",,,,"1616","1616",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSFUSION REACTION INVESTIGATION","45000298","CDM","305","RC","86078","HCPCS",,,"facility","inpatient",,,,"541","541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRANSFUSION REACTION INVESTIGATION","45000298","CDM","305","RC","86078","HCPCS",,,"facility","outpatient",,,,"541","541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARTICLE AGGLUT ANTBDY SCRN","45000339","CDM","302","RC","86403","HCPCS",,,"facility","inpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARTICLE AGGLUT ANTBDY SCRN","45000339","CDM","302","RC","86403","HCPCS",,,"facility","outpatient",,,,"234","234",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEP C SCREEN HIGH RISK/OTHER","45000344","CDM","302","RC","G0472","HCPCS",,,"facility","inpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEP C SCREEN HIGH RISK/OTHER","45000344","CDM","302","RC","G0472","HCPCS",,,"facility","outpatient",,,,"165","165",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARS-COV-2 COVID-19 AB IGG","45000345","CDM","302","RC","86769","HCPCS",,,"facility","inpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARS-COV-2 COVID-19 AB IGG","45000345","CDM","302","RC","86769","HCPCS",,,"facility","outpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARS-COV-2 COVID-19 AB TOTAL","45000346","CDM","302","RC","86769","HCPCS",,,"facility","inpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARS-COV-2 COVID-19 AB TOTAL","45000346","CDM","302","RC","86769","HCPCS",,,"facility","outpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS","45000347","CDM","302","RC","86258","HCPCS",,,"facility","inpatient",,,,"69","69",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS","45000347","CDM","302","RC","86258","HCPCS",,,"facility","outpatient",,,,"69","69",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISSUE TRANSGLUTAMINASE EA IMMUNOGLOBULIN CLASS","45000348","CDM","302","RC","86364","HCPCS",,,"facility","inpatient",,,,"68","68",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISSUE TRANSGLUTAMINASE EA IMMUNOGLOBULIN CLASS","45000348","CDM","302","RC","86364","HCPCS",,,"facility","outpatient",,,,"68","68",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IA INFECTIONS AGT AB QUANT","45000349","CDM","302","RC","86317","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IA INFECTIONS AGT AB QUANT","45000349","CDM","302","RC","86317","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PPD SKIN TEST","45000601","CDM","302","RC","86580","HCPCS",,,"facility","inpatient",,,,"71","71",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PPD SKIN TEST","45000601","CDM","302","RC","86580","HCPCS",,,"facility","outpatient",,,,"71","71",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLAMYDIA PNEUMONIAE, PCR","45000612","CDM","306","RC","87486","HCPCS",,,"facility","inpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLAMYDIA PNEUMONIAE, PCR","45000612","CDM","306","RC","87486","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIMEN CONCENTRATION","46000000","CDM","306","RC","87015","HCPCS",,,"facility","inpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIMEN CONCENTRATION","46000000","CDM","306","RC","87015","HCPCS",,,"facility","outpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BLOOD","46000001","CDM","306","RC","87040","HCPCS",,,"facility","inpatient",,,,"469","469",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BLOOD","46000001","CDM","306","RC","87040","HCPCS",,,"facility","outpatient",,,,"469","469",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE STOOL SALMONELLA AND  SHIGELLA","46000002","CDM","306","RC","87045","HCPCS",,,"facility","inpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE STOOL SALMONELLA AND  SHIGELLA","46000002","CDM","306","RC","87045","HCPCS",,,"facility","outpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE STOOL CAMPHYLOBACTER EA PLATE","46000003","CDM","306","RC","87046","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE STOOL CAMPHYLOBACTER EA PLATE","46000003","CDM","306","RC","87046","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE STOOL OTHER EA PLATE","46000005","CDM","306","RC","87046","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE STOOL OTHER EA PLATE","46000005","CDM","306","RC","87046","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BIOPSY","46000012","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BIOPSY","46000012","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE CATHETER TIP","46000014","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE CATHETER TIP","46000014","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"266","266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE EAR","46000017","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE EAR","46000017","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE EYE","46000019","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE EYE","46000019","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FLUID","46000020","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FLUID","46000020","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE GENITAL","46000021","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE GENITAL","46000021","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE LEGIONELLA","46000022","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE LEGIONELLA","46000022","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT NASAL","46000024","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT NASAL","46000024","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT OTHER SOURCE AEROBIC NOT UR/BLD/STL","46000025","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT OTHER SOURCE AEROBIC NOT UR/BLD/STL","46000025","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE SPUTUM","46000029","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE SPUTUM","46000029","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE QUANTITATIVE ANAEROBIC","46000035","CDM","306","RC","87073","HCPCS",,,"facility","inpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE QUANTITATIVE ANAEROBIC","46000035","CDM","306","RC","87073","HCPCS",,,"facility","outpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BACTERIAL ANAEROBIC NOT BLOOD","46000036","CDM","306","RC","87075","HCPCS",,,"facility","inpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BACTERIAL ANAEROBIC NOT BLOOD","46000036","CDM","306","RC","87075","HCPCS",,,"facility","outpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FLUID (ANAEROBIC)","46000037","CDM","306","RC","87075","HCPCS",,,"facility","inpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FLUID (ANAEROBIC)","46000037","CDM","306","RC","87075","HCPCS",,,"facility","outpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE TISSUE (ANAEROBIC)","46000038","CDM","306","RC","87075","HCPCS",,,"facility","inpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE TISSUE (ANAEROBIC)","46000038","CDM","306","RC","87075","HCPCS",,,"facility","outpatient",,,,"269","269",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BACTERIAL ANAEROBIC ID","46000040","CDM","306","RC","87076","HCPCS",,,"facility","inpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BACTERIAL ANAEROBIC ID","46000040","CDM","306","RC","87076","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BACTERIAL AEROBIC ID","46000041","CDM","306","RC","87077","HCPCS",,,"facility","inpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BACTERIAL AEROBIC ID","46000041","CDM","306","RC","87077","HCPCS",,,"facility","outpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BETA STREP A ONLY","46000042","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE BETA STREP A ONLY","46000042","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE GC SCREEN","46000043","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE GC SCREEN","46000043","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE GROUP B STREP SCREEN","46000044","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE GROUP B STREP SCREEN","46000044","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE LEGIONELLA SCREEN","46000046","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE LEGIONELLA SCREEN","46000046","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE MRSA SCREEN","46000047","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE MRSA SCREEN","46000047","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE SCREEN BORDETELLA PERTUSSUS","46000048","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE SCREEN BORDETELLA PERTUSSUS","46000048","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"201","201",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE SCREEN ONLY","46000050","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE SCREEN ONLY","46000050","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE VRE SCREEN","46000051","CDM","306","RC","87081","HCPCS",,,"facility","inpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE VRE SCREEN","46000051","CDM","306","RC","87081","HCPCS",,,"facility","outpatient",,,,"208","208",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE URINE COLONY COUNT ONLY","46000053","CDM","306","RC","87086","HCPCS",,,"facility","inpatient",,,,"237","237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE URINE COLONY COUNT ONLY","46000053","CDM","306","RC","87086","HCPCS",,,"facility","outpatient",,,,"237","237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE URINE ID EA ISOLATE","46000054","CDM","306","RC","87088","HCPCS",,,"facility","inpatient",,,,"160","160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE URINE ID EA ISOLATE","46000054","CDM","306","RC","87088","HCPCS",,,"facility","outpatient",,,,"160","160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS SKIN HAIR NAIL","46000055","CDM","306","RC","87101","HCPCS",,,"facility","inpatient",,,,"63","63",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS SKIN HAIR NAIL","46000055","CDM","306","RC","87101","HCPCS",,,"facility","outpatient",,,,"63","63",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS OTHER SOURCE","46000056","CDM","306","RC","87102","HCPCS",,,"facility","inpatient",,,,"175","175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS OTHER SOURCE","46000056","CDM","306","RC","87102","HCPCS",,,"facility","outpatient",,,,"175","175",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS BLOOD","46000057","CDM","306","RC","87103","HCPCS",,,"facility","inpatient",,,,"311","311",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS BLOOD","46000057","CDM","306","RC","87103","HCPCS",,,"facility","outpatient",,,,"311","311",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS YEAST ID","46000058","CDM","306","RC","87106","HCPCS",,,"facility","inpatient",,,,"222","222",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS YEAST ID","46000058","CDM","306","RC","87106","HCPCS",,,"facility","outpatient",,,,"222","222",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS MOLD ID","46000059","CDM","306","RC","87107","HCPCS",,,"facility","inpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE FUNGUS MOLD ID","46000059","CDM","306","RC","87107","HCPCS",,,"facility","outpatient",,,,"155","155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MYCOPLASMA CULTURE","46000060","CDM","306","RC","87109","HCPCS",,,"facility","inpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MYCOPLASMA CULTURE","46000060","CDM","306","RC","87109","HCPCS",,,"facility","outpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFB CULTURE","46000063","CDM","306","RC","87116","HCPCS",,,"facility","inpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFB CULTURE","46000063","CDM","306","RC","87116","HCPCS",,,"facility","outpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFB CULTURE (SPUTUM)","46000064","CDM","306","RC","87116","HCPCS",,,"facility","inpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFB CULTURE (SPUTUM)","46000064","CDM","306","RC","87116","HCPCS",,,"facility","outpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFB CULTURE BLOOD","46000065","CDM","306","RC","87116","HCPCS",,,"facility","inpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFB CULTURE BLOOD","46000065","CDM","306","RC","87116","HCPCS",,,"facility","outpatient",,,,"168","168",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFB ISOLATE ID","46000066","CDM","306","RC","87118","HCPCS",,,"facility","inpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AFB ISOLATE ID","46000066","CDM","306","RC","87118","HCPCS",,,"facility","outpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE TYPING FLUORESCENT","46000067","CDM","306","RC","87140","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE TYPING FLUORESCENT","46000067","CDM","306","RC","87140","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE TYPING IMMUNOLOGIC","46000072","CDM","306","RC","87147","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE TYPING IMMUNOLOGIC","46000072","CDM","306","RC","87147","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE TYPING BY NUCLEIC ACID PROBE","46000074","CDM","306","RC","87149","HCPCS",,,"facility","inpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE TYPING BY NUCLEIC ACID PROBE","46000074","CDM","306","RC","87149","HCPCS",,,"facility","outpatient",,,,"226","226",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MACRO EXAM PARASITE","46000078","CDM","306","RC","87169","HCPCS",,,"facility","inpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MACRO EXAM PARASITE","46000078","CDM","306","RC","87169","HCPCS",,,"facility","outpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PINWORM CELLOPHANE TAPE","46000079","CDM","306","RC","87172","HCPCS",,,"facility","inpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PINWORM CELLOPHANE TAPE","46000079","CDM","306","RC","87172","HCPCS",,,"facility","outpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISSUE HOMOGENIZATION","46000080","CDM","306","RC","87176","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISSUE HOMOGENIZATION","46000080","CDM","306","RC","87176","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OVA AND PARASITES W/ CONCENTRATION","46000081","CDM","306","RC","87177","HCPCS",,,"facility","inpatient",,,,"46","46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OVA AND PARASITES W/ CONCENTRATION","46000081","CDM","306","RC","87177","HCPCS",,,"facility","outpatient",,,,"46","46",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUSCEPTIBILITY BY E TEST","46000082","CDM","306","RC","87181","HCPCS",,,"facility","inpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUSCEPTIBILITY BY E TEST","46000082","CDM","306","RC","87181","HCPCS",,,"facility","outpatient",,,,"105","105",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUSCEPTIBILITY KB DISK LESS THAN OR EQUAL TO 12 AGENTS","46000083","CDM","306","RC","87184","HCPCS",,,"facility","inpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUSCEPTIBILITY KB DISK LESS THAN OR EQUAL TO 12 AGENTS","46000083","CDM","306","RC","87184","HCPCS",,,"facility","outpatient",,,,"107","107",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUSCEPTIBILITY BY ENZYME DETECT","46000084","CDM","306","RC","87185","HCPCS",,,"facility","inpatient",,,,"72","72",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUSCEPTIBILITY BY ENZYME DETECT","46000084","CDM","306","RC","87185","HCPCS",,,"facility","outpatient",,,,"72","72",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUSCEPTIBILITY BY MIC","46000085","CDM","306","RC","87186","HCPCS",,,"facility","inpatient",,,,"301","301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SUSCEPTIBILITY BY MIC","46000085","CDM","306","RC","87186","HCPCS",,,"facility","outpatient",,,,"301","301",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR GRAM STAIN","46000088","CDM","306","RC","87205","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR GRAM STAIN","46000088","CDM","306","RC","87205","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR WRIGHT STAIN","46000089","CDM","306","RC","87205","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR WRIGHT STAIN","46000089","CDM","306","RC","87205","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STOOL FOR WBC'S","46000090","CDM","306","RC","87205","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STOOL FOR WBC'S","46000090","CDM","306","RC","87205","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR AFB STAIN","46000091","CDM","306","RC","87206","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR AFB STAIN","46000091","CDM","306","RC","87206","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR CRYPTOSPORIDIUM","46000092","CDM","306","RC","87206","HCPCS",,,"facility","inpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR CRYPTOSPORIDIUM","46000092","CDM","306","RC","87206","HCPCS",,,"facility","outpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR FLUORESCENT AND/OR ACID FAST","46000093","CDM","306","RC","87206","HCPCS",,,"facility","inpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR FLUORESCENT AND/OR ACID FAST","46000093","CDM","306","RC","87206","HCPCS",,,"facility","outpatient",,,,"157","157",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR INCLUSION BODIES PARASITE","46000096","CDM","306","RC","87207","HCPCS",,,"facility","inpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR INCLUSION BODIES PARASITE","46000096","CDM","306","RC","87207","HCPCS",,,"facility","outpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR MALARIA","46000097","CDM","306","RC","87207","HCPCS",,,"facility","inpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR MALARIA","46000097","CDM","306","RC","87207","HCPCS",,,"facility","outpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR COMPLEX STAIN OVA AND PARASITE","46000098","CDM","306","RC","87209","HCPCS",,,"facility","inpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR COMPLEX STAIN OVA AND PARASITE","46000098","CDM","306","RC","87209","HCPCS",,,"facility","outpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDIA INK PREP CSF","46000099","CDM","306","RC","87210","HCPCS",,,"facility","inpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDIA INK PREP CSF","46000099","CDM","306","RC","87210","HCPCS",,,"facility","outpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR WET MOUNT","46000100","CDM","306","RC","87210","HCPCS",,,"facility","inpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SMEAR WET MOUNT","46000100","CDM","306","RC","87210","HCPCS",,,"facility","outpatient",,,,"243","243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KOH PREP SKIN HAIR NAIL","46000101","CDM","306","RC","87220","HCPCS",,,"facility","inpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KOH PREP SKIN HAIR NAIL","46000101","CDM","306","RC","87220","HCPCS",,,"facility","outpatient",,,,"186","186",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE CMV","46000105","CDM","306","RC","87252","HCPCS",,,"facility","inpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE CMV","46000105","CDM","306","RC","87252","HCPCS",,,"facility","outpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE HERPES","46000106","CDM","306","RC","87252","HCPCS",,,"facility","inpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE HERPES","46000106","CDM","306","RC","87252","HCPCS",,,"facility","outpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE V ZOSTER","46000108","CDM","306","RC","87252","HCPCS",,,"facility","inpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE V ZOSTER","46000108","CDM","306","RC","87252","HCPCS",,,"facility","outpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE VIRAL","46000109","CDM","306","RC","87252","HCPCS",,,"facility","inpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE VIRAL","46000109","CDM","306","RC","87252","HCPCS",,,"facility","outpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE HSV","46000112","CDM","306","RC","87255","HCPCS",,,"facility","inpatient",,,,"708","708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE HSV","46000112","CDM","306","RC","87255","HCPCS",,,"facility","outpatient",,,,"708","708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADENOVIRUS DFA","46000114","CDM","306","RC","87260","HCPCS",,,"facility","inpatient",,,,"184","184",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADENOVIRUS DFA","46000114","CDM","306","RC","87260","HCPCS",,,"facility","outpatient",,,,"184","184",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HSV TYPE 2 DFA","46000119","CDM","306","RC","87273","HCPCS",,,"facility","inpatient",,,,"57","57",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HSV TYPE 2 DFA","46000119","CDM","306","RC","87273","HCPCS",,,"facility","outpatient",,,,"57","57",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HSV TYPE 1 DFA","46000120","CDM","306","RC","87274","HCPCS",,,"facility","inpatient",,,,"27","27",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HSV TYPE 1 DFA","46000120","CDM","306","RC","87274","HCPCS",,,"facility","outpatient",,,,"27","27",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA B DFA","46000121","CDM","306","RC","87275","HCPCS",,,"facility","inpatient",,,,"160","160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA B DFA","46000121","CDM","306","RC","87275","HCPCS",,,"facility","outpatient",,,,"160","160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA A DFA","46000122","CDM","306","RC","87276","HCPCS",,,"facility","inpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA A DFA","46000122","CDM","306","RC","87276","HCPCS",,,"facility","outpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEGIONELLA PNEUMOPHILA DFA","46000123","CDM","306","RC","87278","HCPCS",,,"facility","inpatient",,,,"260","260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LEGIONELLA PNEUMOPHILA DFA","46000123","CDM","306","RC","87278","HCPCS",,,"facility","outpatient",,,,"260","260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARAINFLUENZA DFA","46000124","CDM","306","RC","87279","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARAINFLUENZA DFA","46000124","CDM","306","RC","87279","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RSV DFA","46000128","CDM","306","RC","87280","HCPCS",,,"facility","inpatient",,,,"246","246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RSV DFA","46000128","CDM","306","RC","87280","HCPCS",,,"facility","outpatient",,,,"246","246",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VARICELLA ZOSTER DFA","46000130","CDM","306","RC","87290","HCPCS",,,"facility","inpatient",,,,"272","272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VARICELLA ZOSTER DFA","46000130","CDM","306","RC","87290","HCPCS",,,"facility","outpatient",,,,"272","272",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C DIFFICILE TOXIN EIA","46000131","CDM","306","RC","87324","HCPCS",,,"facility","inpatient",,,,"194","194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C DIFFICILE TOXIN EIA","46000131","CDM","306","RC","87324","HCPCS",,,"facility","outpatient",,,,"194","194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYPTOSPORIDIUM AG EIA","46000133","CDM","306","RC","87328","HCPCS",,,"facility","inpatient",,,,"122","122",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYPTOSPORIDIUM AG EIA","46000133","CDM","306","RC","87328","HCPCS",,,"facility","outpatient",,,,"122","122",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GIARDIA AG EIA","46000134","CDM","306","RC","87329","HCPCS",,,"facility","inpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GIARDIA AG EIA","46000134","CDM","306","RC","87329","HCPCS",,,"facility","outpatient",,,,"161","161",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG H PYLORI (NOT STOOL) EIA","46000139","CDM","306","RC","87339","HCPCS",,,"facility","inpatient",,,,"89","89",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG H PYLORI (NOT STOOL) EIA","46000139","CDM","306","RC","87339","HCPCS",,,"facility","outpatient",,,,"89","89",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B SURFACE AG","46000140","CDM","306","RC","87340","HCPCS",,,"facility","inpatient",,,,"153","153",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B SURFACE AG","46000140","CDM","306","RC","87340","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B SURFACE AG NEUTRALIZATION","46000141","CDM","306","RC","87341","HCPCS",,,"facility","inpatient",,,,"43","43",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B SURFACE AG NEUTRALIZATION","46000141","CDM","306","RC","87341","HCPCS",,,"facility","outpatient",,,,"43","43",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA AG A OR B EA","46000146","CDM","306","RC","87400","HCPCS",,,"facility","inpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA AG A OR B EA","46000146","CDM","306","RC","87400","HCPCS",,,"facility","outpatient",,,,"162","162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RSV AG EIA","46000147","CDM","306","RC","87420","HCPCS",,,"facility","inpatient",,,,"357","357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RSV AG EIA","46000147","CDM","306","RC","87420","HCPCS",,,"facility","outpatient",,,,"357","357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROTAVIRUS AG EIA","46000148","CDM","306","RC","87425","HCPCS",,,"facility","inpatient",,,,"211","211",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ROTAVIRUS AG EIA","46000148","CDM","306","RC","87425","HCPCS",,,"facility","outpatient",,,,"211","211",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STREP GROUP A AG EIA","46000150","CDM","306","RC","87430","HCPCS",,,"facility","inpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STREP GROUP A AG EIA","46000150","CDM","306","RC","87430","HCPCS",,,"facility","outpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLAMYDIA TRACH AMPLIFIED PROBE","46000156","CDM","306","RC","87491","HCPCS",,,"facility","inpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHLAMYDIA TRACH AMPLIFIED PROBE","46000156","CDM","306","RC","87491","HCPCS",,,"facility","outpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GARDNERELLA VAGINALIS DNA DIRECT PROBE","46000161","CDM","306","RC","87510","HCPCS",,,"facility","inpatient",,,,"479","479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GARDNERELLA VAGINALIS DNA DIRECT PROBE","46000161","CDM","306","RC","87510","HCPCS",,,"facility","outpatient",,,,"479","479",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HSV AMPLIFIED PROBE","46000171","CDM","306","RC","87529","HCPCS",,,"facility","inpatient",,,,"258","258",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HSV AMPLIFIED PROBE","46000171","CDM","306","RC","87529","HCPCS",,,"facility","outpatient",,,,"258","258",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MYCOBACTERIA TB AMPLIFIED PROBE","46000180","CDM","306","RC","87556","HCPCS",,,"facility","inpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MYCOBACTERIA TB AMPLIFIED PROBE","46000180","CDM","306","RC","87556","HCPCS",,,"facility","outpatient",,,,"425","425",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MYCOPLASMA AMPLIFIED NA PROBE","46000182","CDM","306","RC","87581","HCPCS",,,"facility","inpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MYCOPLASMA AMPLIFIED NA PROBE","46000182","CDM","306","RC","87581","HCPCS",,,"facility","outpatient",,,,"323","323",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GC AMPLIFIED PROBE","46000184","CDM","306","RC","87591","HCPCS",,,"facility","inpatient",,,,"285","285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GC AMPLIFIED PROBE","46000184","CDM","306","RC","87591","HCPCS",,,"facility","outpatient",,,,"247","247",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRICHOMONAS VAG DIRECT PROBE","46000186","CDM","306","RC","87660","HCPCS",,,"facility","inpatient",,,,"152","152",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRICHOMONAS VAG DIRECT PROBE","46000186","CDM","306","RC","87660","HCPCS",,,"facility","outpatient",,,,"152","152",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFECT AGENT POLYVAL DFA","46000200","CDM","306","RC","87300","HCPCS",,,"facility","inpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFECT AGENT POLYVAL DFA","46000200","CDM","306","RC","87300","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AG DETECT NOS DNA AMP","46000210","CDM","306","RC","87798","HCPCS",,,"facility","inpatient",,,,"437","437",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AG DETECT NOS DNA AMP","46000210","CDM","306","RC","87798","HCPCS",,,"facility","outpatient",,,,"437","437",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AG DETECT EIA MULT STEP","46000215","CDM","306","RC","87449","HCPCS",,,"facility","inpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AG DETECT EIA MULT STEP","46000215","CDM","306","RC","87449","HCPCS",,,"facility","outpatient",,,,"185","185",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE CSF","46000217","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"423","423",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULTURE CSF","46000217","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIV-1 AG W/HIV-1/HIV-2 AB","46000219","CDM","306","RC","87389","HCPCS",,,"facility","inpatient",,,,"316","316",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIV-1 AG W/HIV-1/HIV-2 AB","46000219","CDM","306","RC","87389","HCPCS",,,"facility","outpatient",,,,"316","316",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT WOUND","46000221","CDM","306","RC","87070","HCPCS",,,"facility","inpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT WOUND","46000221","CDM","306","RC","87070","HCPCS",,,"facility","outpatient",,,,"306","306",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SER BACTERICIDAL TTR","46000223","CDM","306","RC","87197","HCPCS",,,"facility","inpatient",,,,"320","320",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SER BACTERICIDAL TTR","46000223","CDM","306","RC","87197","HCPCS",,,"facility","outpatient",,,,"320","320",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG M AVIUM AMP PRB","46000224","CDM","306","RC","87561","HCPCS",,,"facility","inpatient",,,,"633","633",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG M AVIUM AMP PRB","46000224","CDM","306","RC","87561","HCPCS",,,"facility","outpatient",,,,"633","633",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C DIFF AMPLIFIED PROBE","46000227","CDM","306","RC","87493","HCPCS",,,"facility","inpatient",,,,"421","421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C DIFF AMPLIFIED PROBE","46000227","CDM","306","RC","87493","HCPCS",,,"facility","outpatient",,,,"421","421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA DNA AMP PROBE","46000229","CDM","306","RC","87502","HCPCS",,,"facility","inpatient",,,,"640","640",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA DNA AMP PROBE","46000229","CDM","306","RC","87502","HCPCS",,,"facility","outpatient",,,,"640","640",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA DNA AMP PROB >2 TYPES","46000230","CDM","306","RC","87503","HCPCS",,,"facility","inpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA DNA AMP PROB >2 TYPES","46000230","CDM","306","RC","87503","HCPCS",,,"facility","outpatient",,,,"81","81",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYPTOCOCCAL ANTIGEN BY IMMUNOASSAY","46000232","CDM","306","RC","87899","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYPTOCOCCAL ANTIGEN BY IMMUNOASSAY","46000232","CDM","306","RC","87899","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HPV HIGH-RISK TYPES W/ POOLED RESULTS","46000234","CDM","306","RC","87624","HCPCS",,,"facility","inpatient",,,,"568","568",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HPV HIGH-RISK TYPES W/ POOLED RESULTS","46000234","CDM","306","RC","87624","HCPCS",,,"facility","outpatient",,,,"568","568",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HPV TYPES 16 & 18 ONLY","46000235","CDM","306","RC","87625","HCPCS",,,"facility","inpatient",,,,"76","76",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HPV TYPES 16 & 18 ONLY","46000235","CDM","306","RC","87625","HCPCS",,,"facility","outpatient",,,,"73","73",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFECT AGENT ANTIGEN BY IMMUNOASSAY NOS","46000236","CDM","306","RC","87899","HCPCS",,,"facility","inpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFECT AGENT ANTIGEN BY IMMUNOASSAY NOS","46000236","CDM","306","RC","87899","HCPCS",,,"facility","outpatient",,,,"212","212",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RESP VIRUS 3-5 TARGETS","46000238","CDM","306","RC","87631","HCPCS",,,"facility","inpatient",,,,"1286","1286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RESP VIRUS 3-5 TARGETS","46000238","CDM","306","RC","87631","HCPCS",,,"facility","outpatient",,,,"1286","1286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RESP VIRUS 12-25 TARGETS","46000239","CDM","306","RC","87633","HCPCS",,,"facility","inpatient",,,,"1350","1350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RESP VIRUS 12-25 TARGETS","46000239","CDM","306","RC","87633","HCPCS",,,"facility","outpatient",,,,"1350","1350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT TYPE DNA/RNA AMPLIFIED PROBE EA","46000240","CDM","306","RC","87150","HCPCS",,,"facility","inpatient",,,,"268","268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CULT TYPE DNA/RNA AMPLIFIED PROBE EA","46000240","CDM","306","RC","87150","HCPCS",,,"facility","outpatient",,,,"268","268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CNS DNA AMP PROBE TYPE 12-25","46000246","CDM","306","RC","87483","HCPCS",,,"facility","inpatient",,,,"1424","1424",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CNS DNA AMP PROBE TYPE 12-25","46000246","CDM","306","RC","87483","HCPCS",,,"facility","outpatient",,,,"1424","1424",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RSV DNA/RNA AMP PROBE","46000247","CDM","306","RC","87634","HCPCS",,,"facility","inpatient",,,,"349","349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RSV DNA/RNA AMP PROBE","46000247","CDM","306","RC","87634","HCPCS",,,"facility","outpatient",,,,"349","349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STREP A AMPLIF NA PROBE","46000248","CDM","306","RC","87651","HCPCS",,,"facility","inpatient",,,,"266","266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG STREP A AMPLIF NA PROBE","46000248","CDM","306","RC","87651","HCPCS",,,"facility","outpatient",,,,"266","266",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IADNA SARS-COV-2 COVID-19 AMP PROBE TQ","46000249","CDM","306","RC","87635","HCPCS",,,"facility","inpatient",,,,"382","382",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IADNA SARS-COV-2 COVID-19 AMP PROBE TQ","46000249","CDM","306","RC","87635","HCPCS",,,"facility","outpatient",,,,"382","382",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARS-COV-2 COVID-19 AMP PROB HI THRUPUT TQ","46000250","CDM","306","RC","U0003","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARS-COV-2 COVID-19 AMP PROB HI THRUPUT TQ","46000250","CDM","306","RC","U0003","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARSCOV2 COVID-19 & INF A&B AMP PRB","46000251","CDM","306","RC","87636","HCPCS",,,"facility","inpatient",,,,"532","532",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARSCOV2 COVID-19 & INF A&B AMP PRB","46000251","CDM","306","RC","87636","HCPCS",,,"facility","outpatient",,,,"532","532",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARSCOV2 COVID-19 & INF A&B&RSV AMP PRB","46000252","CDM","306","RC","87637","HCPCS",,,"facility","inpatient",,,,"605","605",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARSCOV2 COVID-19 & INF A&B&RSV AMP PRB","46000252","CDM","306","RC","87637","HCPCS",,,"facility","outpatient",,,,"605","605",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25","46000253","CDM","306","RC","87507","HCPCS",,,"facility","inpatient",,,,"845","845",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25","46000253","CDM","306","RC","87507","HCPCS",,,"facility","outpatient",,,,"845","845",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COV-19 AMP PRB HI THRUPUT W/IN 2 DAY COLLT","46000254","CDM","306","RC","U0005","HCPCS",,,"facility","inpatient",,,,"25","25",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COV-19 AMP PRB HI THRUPUT W/IN 2 DAY COLLT","46000254","CDM","306","RC","U0005","HCPCS",,,"facility","outpatient",,,,"25","25",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CUL TYP ID BLD PTHGN MULTIPLEX 6+ TRGT","46000255","CDM","306","RC","87154","HCPCS",,,"facility","inpatient",,,,"835","835",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CUL TYP ID BLD PTHGN MULTIPLEX 6+ TRGT","46000255","CDM","306","RC","87154","HCPCS",,,"facility","outpatient",,,,"835","835",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARS-COV-2 COVID19 ANTIGEN W/OPTICAL OBS","46000257","CDM","306","RC","87811","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SARS-COV-2 COVID19 ANTIGEN W/OPTICAL OBS","46000257","CDM","306","RC","87811","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPB SCREEN NON-PREGNANT HIGH RISK INDIV","46000258","CDM","306","RC","G0499","HCPCS",,,"facility","inpatient",,,,"180","180",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPB SCREEN NON-PREGNANT HIGH RISK INDIV","46000258","CDM","306","RC","G0499","HCPCS",,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IADNA ORTHOPOXVIRUS AMP PRB TECHNIQUE EA","46000259","CDM","306","RC","87593","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IADNA ORTHOPOXVIRUS AMP PRB TECHNIQUE EA","46000259","CDM","306","RC","87593","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HPV SEP HI-RSK TYP&POOL RSLT","46000260","CDM","306","RC","87626","HCPCS",,,"facility","inpatient",,,,"609","609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HPV SEP HI-RSK TYP&POOL RSLT","46000260","CDM","306","RC","87626","HCPCS",,,"facility","outpatient",,,,"609","609",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIV AG W/HIV1&2 ANTB W/OPTIC","46000261","CDM","306","RC","87806","HCPCS",,,"facility","inpatient",,,,"325","325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HIV AG W/HIV1&2 ANTB W/OPTIC","46000261","CDM","306","RC","87806","HCPCS",,,"facility","outpatient",,,,"325","325",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS AUTOMATED W/ MICROSCOPIC EXAM","47000001","CDM","307","RC","81001","HCPCS",,,"facility","inpatient",,,,"141","141",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS AUTOMATED W/ MICROSCOPIC EXAM","47000001","CDM","307","RC","81001","HCPCS",,,"facility","outpatient",,,,"125","125",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIFIC GRAVITY URINE","47000002","CDM","307","RC","81002","HCPCS",,,"facility","inpatient",,,,"49","49",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIFIC GRAVITY URINE","47000002","CDM","307","RC","81002","HCPCS",,,"facility","outpatient",,,,"49","49",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS MANUAL W/OUT MICROSCOPIC EXAM","47000003","CDM","307","RC","81002","HCPCS",,,"facility","inpatient",,,,"47","47",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS MANUAL W/OUT MICROSCOPIC EXAM","47000003","CDM","307","RC","81002","HCPCS",,,"facility","outpatient",,,,"47","47",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS SINGLE ASSAY","47000005","CDM","307","RC","81002","HCPCS",,,"facility","inpatient",,,,"49","49",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS SINGLE ASSAY","47000005","CDM","307","RC","81002","HCPCS",,,"facility","outpatient",,,,"49","49",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS AUTOMATED W/OUT  MICROSCOPIC EXAM","47000006","CDM","307","RC","81003","HCPCS",,,"facility","inpatient",,,,"102","102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS AUTOMATED W/OUT  MICROSCOPIC EXAM","47000006","CDM","307","RC","81003","HCPCS",,,"facility","outpatient",,,,"102","102",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS QUALITATIVE OR SEMI QUANTITATIVE","47000007","CDM","307","RC","81005","HCPCS",,,"facility","inpatient",,,,"83","83",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG URINALYSIS QUALITATIVE OR SEMI QUANTITATIVE","47000007","CDM","307","RC","81005","HCPCS",,,"facility","outpatient",,,,"83","83",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MICROSCOPIC EXAM URINE","47000008","CDM","307","RC","81015","HCPCS",,,"facility","inpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MICROSCOPIC EXAM URINE","47000008","CDM","307","RC","81015","HCPCS",,,"facility","outpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PREGNANCY SCREEN URINE","47000010","CDM","307","RC","81025","HCPCS",,,"facility","inpatient",,,,"190","190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PREGNANCY SCREEN URINE","47000010","CDM","307","RC","81025","HCPCS",,,"facility","outpatient",,,,"190","190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE","47100001","CDM","309","RC","36415","HCPCS",,,"facility","inpatient",,,,"50","50",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE","47100001","CDM","309","RC","36415","HCPCS",,,"facility","outpatient",,,,"50","50",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS VENIPUNCTURE","47100002","CDM","760","RC","36415","HCPCS",,,"facility","inpatient",,,,"50","50",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OBS VENIPUNCTURE","47100002","CDM","760","RC","36415","HCPCS",,,"facility","outpatient",,,,"50","50",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAPILLARY PUNCTURE","47100003","CDM","300","RC","36416","HCPCS",,,"facility","inpatient",,,,"39","39",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAPILLARY PUNCTURE","47100003","CDM","300","RC","36416","HCPCS",,,"facility","outpatient",,,,"38","38",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CELL COUNT FLUID W/ DIFF","47100005","CDM","309","RC","89051","HCPCS",,,"facility","inpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CELL COUNT FLUID W/ DIFF","47100005","CDM","309","RC","89051","HCPCS",,,"facility","outpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYSTAL ID TISSUE/FLUID NOT URINE","47100006","CDM","309","RC","89060","HCPCS",,,"facility","inpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYSTAL ID TISSUE/FLUID NOT URINE","47100006","CDM","309","RC","89060","HCPCS",,,"facility","outpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAT STAIN QUALITATIVE","47100007","CDM","309","RC","89125","HCPCS",,,"facility","inpatient",,,,"25","25",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAT STAIN QUALITATIVE","47100007","CDM","309","RC","89125","HCPCS",,,"facility","outpatient",,,,"25","25",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EOSINPHILS SMEAR NASAL","47100008","CDM","309","RC","89190","HCPCS",,,"facility","inpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EOSINPHILS SMEAR NASAL","47100008","CDM","309","RC","89190","HCPCS",,,"facility","outpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEMEN MOTILITY/COUNT (NO HUHNER)","47100011","CDM","309","RC","89310","HCPCS",,,"facility","inpatient",,,,"150","150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEMEN MOTILITY/COUNT (NO HUHNER)","47100011","CDM","309","RC","89310","HCPCS",,,"facility","outpatient",,,,"150","150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEMEN ANALYSIS COMPLETE","47100012","CDM","309","RC","89320","HCPCS",,,"facility","inpatient",,,,"253","253",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEMEN ANALYSIS COMPLETE","47100012","CDM","309","RC","89320","HCPCS",,,"facility","outpatient",,,,"253","253",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ARTERIAL PUNCTURE","47100016","CDM","300","RC","36600","HCPCS",,,"facility","inpatient",,,,"401","401",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ARTERIAL PUNCTURE","47100016","CDM","300","RC","36600","HCPCS",,,"facility","outpatient",,,,"393","393",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPUTUM SPEC VIA AEROSOL","47100017","CDM","300","RC","89220","HCPCS",,,"facility","inpatient",,,,"837","837",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPUTUM SPEC VIA AEROSOL","47100017","CDM","300","RC","89220","HCPCS",,,"facility","outpatient",,,,"837","837",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPEC HANDL TO REF LAB","47100023","CDM","309","RC","99001","HCPCS",,,"facility","inpatient",,,"GY","55","55",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG SPEC HANDL TO REF LAB","47100023","CDM","309","RC","99001","HCPCS",,,"facility","outpatient",,,"GY","54","54",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG V CPM REQUEST PROCESSING FEE","47100051","CDM","309","RC",,,,,"facility","inpatient",,,,"123","123",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPM REQUEST PROCESSING FEE","47100051","CDM","309","RC",,,,,"facility","outpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC SLIDE RETRIEVAL 1-20 SLIDES","47100052","CDM","309","RC",,,,,"facility","inpatient",,,,"89","89",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC SLIDE RETRIEVAL 1-20 SLIDES","47100052","CDM","309","RC",,,,,"facility","outpatient",,,,"87","87",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST PAPANICOLAU STAIN EACH","47100053","CDM","309","RC",,,,,"facility","inpatient",,,,"33","33",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST PAPANICOLAU STAIN EACH","47100053","CDM","309","RC",,,,,"facility","outpatient",,,,"32","32",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KIT DRAW","47100060","CDM","309","RC","99001","HCPCS",,,"facility","inpatient",,,"GY","55","55",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG KIT DRAW","47100060","CDM","309","RC","99001","HCPCS",,,"facility","outpatient",,,"GY","54","54",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG CPMC VENIPUNCTURE BTMG","47100063","CDM","309","RC","36415","HCPCS",,,"facility","inpatient",,,,"50","50",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPMC VENIPUNCTURE BTMG","47100063","CDM","309","RC","36415","HCPCS",,,"facility","outpatient",,,,"28","28",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPMC VENIPUNCTURE BTMG PRENATAL","47100064","CDM","309","RC","36415","HCPCS",,,"facility","inpatient",,,,"50","50",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPMC VENIPUNCTURE BTMG PRENATAL","47100064","CDM","309","RC","36415","HCPCS",,,"facility","outpatient",,,,"40","40",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HOPD COVID-19 SPEC COLLECT","47100068","CDM","309","RC","C9803","HCPCS",,,"facility","inpatient",,,,"61","61",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HOPD COVID-19 SPEC COLLECT","47100068","CDM","309","RC","C9803","HCPCS",,,"facility","outpatient",,,,"60","60",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE CDPH PRENATAL","47100070","CDM","309","RC","36415","HCPCS",,,"facility","inpatient",,,,"6","6",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE CDPH PRENATAL","47100070","CDM","309","RC","36415","HCPCS",,,"facility","outpatient",,,,"6","6",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2","47100071","CDM","309","RC","0202U","HCPCS",,,"facility","inpatient",,,,"1553","1553",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NFCT DS BCT/VIR RESPIR DNA/RNA 22 TRGT SARSCOV2","47100071","CDM","309","RC","0202U","HCPCS",,,"facility","outpatient",,,,"1523","1523",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NFCT DS BV&VAGINITIS DNA ALG","47100072","CDM","309","RC","81515","HCPCS",,,"facility","inpatient",,,,"581","581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NFCT DS BV&VAGINITIS DNA ALG","47100072","CDM","309","RC","81515","HCPCS",,,"facility","outpatient",,,,"581","581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY FLUID","48100001","CDM","311","RC","88104","HCPCS",,,"facility","inpatient",,,,"229","229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY FLUID","48100001","CDM","311","RC","88104","HCPCS",,,"facility","outpatient",,,,"229","229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY URINE","48100002","CDM","311","RC","88104","HCPCS",,,"facility","inpatient",,,,"229","229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY URINE","48100002","CDM","311","RC","88104","HCPCS",,,"facility","outpatient",,,,"229","229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY CONCENTRATION TECHNIQUE","48100005","CDM","311","RC","88108","HCPCS",,,"facility","inpatient",,,,"184","184",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY CONCENTRATION TECHNIQUE","48100005","CDM","311","RC","88108","HCPCS",,,"facility","outpatient",,,,"189","189",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY SELECTIVE CELLULAR ENHANCEMENT","48100006","CDM","311","RC","88112","HCPCS",,,"facility","inpatient",,,,"179","179",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY SELECTIVE CELLULAR ENHANCEMENT","48100006","CDM","311","RC","88112","HCPCS",,,"facility","outpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PAP DIAGNOSTIC THIN LAYER PREP","48100007","CDM","311","RC","88142","HCPCS",,,"facility","inpatient",,,,"82","82",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PAP DIAGNOSTIC THIN LAYER PREP","48100007","CDM","311","RC","88142","HCPCS",,,"facility","outpatient",,,,"95","95",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PAP DIAGNOSTIC MANUAL","48100008","CDM","311","RC","88150","HCPCS",,,"facility","inpatient",,,,"59","59",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PAP DIAGNOSTIC MANUAL","48100008","CDM","311","RC","88150","HCPCS",,,"facility","outpatient",,,,"71","71",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY SMEARS OTHER SOURCE","48100009","CDM","311","RC","88160","HCPCS",,,"facility","inpatient",,,,"174","174",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY SMEARS OTHER SOURCE","48100009","CDM","311","RC","88160","HCPCS",,,"facility","outpatient",,,,"174","174",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY SMEARS PREPARATION & INTERPRETATION","48100010","CDM","311","RC","88161","HCPCS",,,"facility","inpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY SMEARS PREPARATION & INTERPRETATION","48100010","CDM","311","RC","88161","HCPCS",,,"facility","outpatient",,,,"207","207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PAP DIAGNOSTIC BY THE BETHESDA SYSTEM METHOD","48100011","CDM","311","RC","88164","HCPCS",,,"facility","inpatient",,,,"170","170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PAP DIAGNOSTIC BY THE BETHESDA SYSTEM METHOD","48100011","CDM","311","RC","88164","HCPCS",,,"facility","outpatient",,,,"170","170",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA ADEQUACY EVALUATION","48100012","CDM","311","RC","88172","HCPCS",,,"facility","inpatient",,,,"237","237",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA ADEQUACY EVALUATION","48100012","CDM","311","RC","88172","HCPCS",,,"facility","outpatient",,,,"284","284",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA INTERPRETATION AND REPORT","48100013","CDM","311","RC","88173","HCPCS",,,"facility","inpatient",,,,"235","235",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FNA INTERPRETATION AND REPORT","48100013","CDM","311","RC","88173","HCPCS",,,"facility","outpatient",,,,"282","282",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DNA CELL CYCLE","48100016","CDM","311","RC","88182","HCPCS",,,"facility","inpatient",,,,"674","674",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DNA CELL CYCLE","48100016","CDM","311","RC","88182","HCPCS",,,"facility","outpatient",,,,"674","674",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CELL MARKER TECHNICAL COMPONENT 1ST CELL MARKER","48100018","CDM","311","RC","88184","HCPCS",,,"facility","inpatient",,,,"285","285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CELL MARKER TECHNICAL COMPONENT 1ST CELL MARKER","48100018","CDM","311","RC","88184","HCPCS",,,"facility","outpatient",,,,"285","285",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CELL MARKER TECHNICAL COMPONENT EA ADDL MARKER","48100019","CDM","311","RC","88185","HCPCS",,,"facility","inpatient",,,,"31","31",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CELL MARKER TECHNICAL COMPONENT EA ADDL MARKER","48100019","CDM","311","RC","88185","HCPCS",,,"facility","outpatient",,,,"37","37",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CELL MARKER INTERPRET 16+","48100022","CDM","311","RC","88189","HCPCS",,,"facility","inpatient",,,,"117","117",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CELL MARKER INTERPRET 16+","48100022","CDM","311","RC","88189","HCPCS",,,"facility","outpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MEAT FIBERS, FECES","48100024","CDM","309","RC","89160","HCPCS",,,"facility","inpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MEAT FIBERS, FECES","48100024","CDM","309","RC","89160","HCPCS",,,"facility","outpatient",,,,"111","111",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY CSF SMR","48100026","CDM","311","RC","88104","HCPCS",,,"facility","inpatient",,,,"229","229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY CSF SMR","48100026","CDM","311","RC","88104","HCPCS",,,"facility","outpatient",,,,"229","229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTP EVL ASP CYTO STY ADD","48100029","CDM","311","RC","88177","HCPCS",,,"facility","inpatient",,,,"49","49",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTP EVL ASP CYTO STY ADD","48100029","CDM","311","RC","88177","HCPCS",,,"facility","outpatient",,,,"59","59",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY EXTENDED STUDY","48100072","CDM","311","RC","88162","HCPCS",,,"facility","inpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYTOLOGY EXTENDED STUDY","48100072","CDM","311","RC","88162","HCPCS",,,"facility","outpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OUTSD COMPR CONSULT","48100073","CDM","312","RC","88325","HCPCS",,,"facility","inpatient",,,,"552","552",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OUTSD COMPR CONSULT","48100073","CDM","312","RC","88325","HCPCS",,,"facility","outpatient",,,,"583","583",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISSUE CULTURE SKIN","48200001","CDM","311","RC","88233","HCPCS",,,"facility","inpatient",,,,"1481","1481",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISSUE CULTURE SKIN","48200001","CDM","311","RC","88233","HCPCS",,,"facility","outpatient",,,,"1481","1481",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISSUE CULTURE BONE MARROW/BLOOD","48200003","CDM","311","RC","88237","HCPCS",,,"facility","inpatient",,,,"263","263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISSUE CULTURE BONE MARROW/BLOOD","48200003","CDM","311","RC","88237","HCPCS",,,"facility","outpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYOPRESERVE/STORAGE CELL","48200004","CDM","311","RC","88240","HCPCS",,,"facility","inpatient",,,,"51","51",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CRYOPRESERVE/STORAGE CELL","48200004","CDM","311","RC","88240","HCPCS",,,"facility","outpatient",,,,"54","54",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHRMOSOME COUNT 15-20 CELLS/ 1 KARYOTYPE","48200006","CDM","311","RC","88262","HCPCS",,,"facility","inpatient",,,,"348","348",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHRMOSOME COUNT 15-20 CELLS/ 1 KARYOTYPE","48200006","CDM","311","RC","88262","HCPCS",,,"facility","outpatient",,,,"348","348",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DNA PROBE CYTOGENETICS EA","48200010","CDM","311","RC","88271","HCPCS",,,"facility","inpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DNA PROBE CYTOGENETICS EA","48200010","CDM","311","RC","88271","HCPCS",,,"facility","outpatient",,,,"132","132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DNA PROBE CYTOGENETICS >100","48200013","CDM","311","RC","88275","HCPCS",,,"facility","inpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DNA PROBE CYTOGENETICS >100","48200013","CDM","311","RC","88275","HCPCS",,,"facility","outpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL PATHOLOGY LEVEL IV","48300002","CDM","312","RC","88305","HCPCS",,,"facility","inpatient",,,,"281","281",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL PATHOLOGY LEVEL IV","48300002","CDM","312","RC","88305","HCPCS",,,"facility","outpatient",,,,"337","337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL PATHOLOGY LEVEL V","48300003","CDM","312","RC","88307","HCPCS",,,"facility","inpatient",,,,"554","554",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL PATHOLOGY LEVEL V","48300003","CDM","312","RC","88307","HCPCS",,,"facility","outpatient",,,,"578","578",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL PATHOLOGY LEVEL VI","48300004","CDM","312","RC","88309","HCPCS",,,"facility","inpatient",,,,"886","886",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL PATHOLOGY LEVEL VI","48300004","CDM","312","RC","88309","HCPCS",,,"facility","outpatient",,,,"1063","1063",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECALCIFICATION","48300005","CDM","312","RC","88311","HCPCS",,,"facility","inpatient",,,,"59","59",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECALCIFICATION","48300005","CDM","312","RC","88311","HCPCS",,,"facility","outpatient",,,,"71","71",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIAL STAIN GROUP I MICROORGANISMS","48300006","CDM","312","RC","88312","HCPCS",,,"facility","inpatient",,,,"171","171",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIAL STAIN GROUP I MICROORGANISMS","48300006","CDM","312","RC","88312","HCPCS",,,"facility","outpatient",,,,"177","177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIAL STAIN GROUP II","48300007","CDM","312","RC","88313","HCPCS",,,"facility","inpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SPECIAL STAIN GROUP II","48300007","CDM","312","RC","88313","HCPCS",,,"facility","outpatient",,,,"127","127",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HISTOCHEMICAL STAIN FROZEN SECTION","48300008","CDM","312","RC","88314","HCPCS",,,"facility","inpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HISTOCHEMICAL STAIN FROZEN SECTION","48300008","CDM","312","RC","88314","HCPCS",,,"facility","outpatient",,,,"156","156",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENZYME HISTOCHEMISTRY","48300010","CDM","312","RC","88319","HCPCS",,,"facility","inpatient",,,,"415","415",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ENZYME HISTOCHEMISTRY","48300010","CDM","312","RC","88319","HCPCS",,,"facility","outpatient",,,,"415","415",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OUTSIDE SLIDE CONSULT","48300011","CDM","312","RC","88321","HCPCS",,,"facility","inpatient",,,,"349","349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OUTSIDE SLIDE CONSULT","48300011","CDM","312","RC","88321","HCPCS",,,"facility","outpatient",,,,"349","349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OUTSIDE SLIDE CONSULT PREP","48300012","CDM","312","RC","88323","HCPCS",,,"facility","inpatient",,,,"232","232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OUTSIDE SLIDE CONSULT PREP","48300012","CDM","312","RC","88323","HCPCS",,,"facility","outpatient",,,,"232","232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PATH FROZEN SECTION 1 BLOCK","48300014","CDM","312","RC","88331","HCPCS",,,"facility","inpatient",,,,"239","239",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PATH FROZEN SECTION 1 BLOCK","48300014","CDM","312","RC","88331","HCPCS",,,"facility","outpatient",,,,"287","287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PATH FROZEN SECTION EA ADDL BLOCK","48300015","CDM","312","RC","88332","HCPCS",,,"facility","inpatient",,,,"282","282",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PATH FROZEN SECTION EA ADDL BLOCK","48300015","CDM","312","RC","88332","HCPCS",,,"facility","outpatient",,,,"282","282",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRAOPERATIVE CYTOPATH CONSULT INITIAL SITE","48300016","CDM","312","RC","88333","HCPCS",,,"facility","inpatient",,,,"232","232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRAOPERATIVE CYTOPATH CONSULT INITIAL SITE","48300016","CDM","312","RC","88333","HCPCS",,,"facility","outpatient",,,,"278","278",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRAOPERATIVE CYTOPATH CONSULT EA ADDL SITE","48300017","CDM","312","RC","88334","HCPCS",,,"facility","inpatient",,,,"110","110",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTRAOPERATIVE CYTOPATH CONSULT EA ADDL SITE","48300017","CDM","312","RC","88334","HCPCS",,,"facility","outpatient",,,,"115","115",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOFL PER SPEC SINGLE AB STAIN PROC INITIAL","48300019","CDM","312","RC","88346","HCPCS",,,"facility","inpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOFL PER SPEC SINGLE AB STAIN PROC INITIAL","48300019","CDM","312","RC","88346","HCPCS",,,"facility","outpatient",,,,"215","215",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELECTRON MICROSCOPY DIAGNOSTIC","48300020","CDM","312","RC","88348","HCPCS",,,"facility","inpatient",,,,"1177","1177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELECTRON MICROSCOPY DIAGNOSTIC","48300020","CDM","312","RC","88348","HCPCS",,,"facility","outpatient",,,,"1177","1177",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL  PATHOLOGY LEVEL I","48300021","CDM","312","RC","88300","HCPCS",,,"facility","inpatient",,,,"82","82",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL  PATHOLOGY LEVEL I","48300021","CDM","312","RC","88300","HCPCS",,,"facility","outpatient",,,,"98","98",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL PATHOLOGY LEVEL II","48300022","CDM","312","RC","88302","HCPCS",,,"facility","inpatient",,,,"158","158",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURGICAL PATHOLOGY LEVEL II","48300022","CDM","312","RC","88302","HCPCS",,,"facility","outpatient",,,,"190","190",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISS EXAM MOLECULAR STUDY","48300028","CDM","310","RC","88387","HCPCS",,,"facility","inpatient",,,,"1067","1067",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISS EXAM MOLECULAR STUDY","48300028","CDM","310","RC","88387","HCPCS",,,"facility","outpatient",,,,"1132","1132",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISS EX MOLE STUDY ADD-ON","48300029","CDM","310","RC","88388","HCPCS",,,"facility","inpatient",,,,"948","948",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TISS EX MOLE STUDY ADD-ON","48300029","CDM","310","RC","88388","HCPCS",,,"facility","outpatient",,,,"948","948",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TUMOR IMMUNOHISTOCHEM MAN","48300033","CDM","310","RC","88360","HCPCS",,,"facility","inpatient",,,,"244","244",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TUMOR IMMUNOHISTOCHEM MAN","48300033","CDM","310","RC","88360","HCPCS",,,"facility","outpatient",,,,"293","293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC 1 H&E SLIDE FOR TECHNICAL PREP ONLY","48300067","CDM","312","RC",,,,,"facility","inpatient",,,,"14","14",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC 1 H&E SLIDE FOR TECHNICAL PREP ONLY","48300067","CDM","312","RC",,,,,"facility","outpatient",,,,"15","15",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOHISTO AB STAIN INITIAL SINGLE AB","48300068","CDM","310","RC","88342","HCPCS",,,"facility","inpatient",,,,"265","265",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOHISTO AB STAIN INITIAL SINGLE AB","48300068","CDM","310","RC","88342","HCPCS",,,"facility","outpatient",,,,"298","298",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOHISTO ANTIBODY SLIDE EA ADD","48300069","CDM","310","RC","88341","HCPCS",,,"facility","inpatient",,,,"192","192",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOHISTO ANTIBODY SLIDE EA ADD","48300069","CDM","310","RC","88341","HCPCS",,,"facility","outpatient",,,,"203","203",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOHISTO ANTIBODY SLIDE MULTI","48300070","CDM","310","RC","88344","HCPCS",,,"facility","inpatient",,,,"408","408",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOHISTO ANTIBODY SLIDE MULTI","48300070","CDM","310","RC","88344","HCPCS",,,"facility","outpatient",,,,"408","408",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROSTATE BIOPSY  ANY METHOD","48300071","CDM","310","RC","G0416","HCPCS",,,"facility","inpatient",,,,"618","618",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PROSTATE BIOPSY  ANY METHOD","48300071","CDM","310","RC","G0416","HCPCS",,,"facility","outpatient",,,,"722","722",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOFL PER SPEC SINGLE AB STAIN PROC EA ADDL","48300072","CDM","312","RC","88350","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNOFL PER SPEC SINGLE AB STAIN PROC EA ADDL","48300072","CDM","312","RC","88350","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST RECUT UNSTAINED SLIDES EACH","48300075","CDM","312","RC",,,,,"facility","inpatient",,,,"5","5",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST RECUT UNSTAINED SLIDES EACH","48300075","CDM","312","RC",,,,,"facility","outpatient",,,,"5","5",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST H & E SLIDE EACH","48300076","CDM","312","RC",,,,,"facility","inpatient",,,,"16","16",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST H & E SLIDE EACH","48300076","CDM","312","RC",,,,,"facility","outpatient",,,,"17","17",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST SPECIAL STAIN SLIDE EACH","48300077","CDM","312","RC",,,,,"facility","inpatient",,,,"58","58",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST SPECIAL STAIN SLIDE EACH","48300077","CDM","312","RC",,,,,"facility","outpatient",,,,"62","62",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST TISSUE BLOCK EACH","48300078","CDM","312","RC",,,,,"facility","inpatient",,,,"21","21",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST TISSUE BLOCK EACH","48300078","CDM","312","RC",,,,,"facility","outpatient",,,,"22","22",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST PATIENT PATHOLOGY RECORD EACH PATIENT","48300079","CDM","312","RC",,,,,"facility","inpatient",,,,"16","16",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST PATIENT PATHOLOGY RECORD EACH PATIENT","48300079","CDM","312","RC",,,,,"facility","outpatient",,,,"17","17",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST IHC SLIDE EACH","48300080","CDM","312","RC",,,,,"facility","inpatient",,,,"64","64",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG V CPMC REQUEST IHC SLIDE EACH","48300080","CDM","312","RC",,,,,"facility","outpatient",,,,"68","68",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN SITU HYBRIDIZATION MANUAL","48300081","CDM","310","RC","88368","HCPCS",,,"facility","inpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN SITU HYBRIDIZATION MANUAL","48300081","CDM","310","RC","88368","HCPCS",,,"facility","outpatient",,,,"230","230",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN SITU HYBRIDIZATION MANUAL EA ADD","48300082","CDM","310","RC","88369","HCPCS",,,"facility","inpatient",,,,"143","143",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN SITU HYBRIDIZATION MANUAL EA ADD","48300082","CDM","310","RC","88369","HCPCS",,,"facility","outpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XM ARCHIV TISS MOLEC ANAL","48300083","CDM","310","RC","88363","HCPCS",,,"facility","inpatient",,,,"100","100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XM ARCHIV TISS MOLEC ANAL","48300083","CDM","310","RC","88363","HCPCS",,,"facility","outpatient",,,,"106","106",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS HEMOFILTRATION","50000000","CDM","801","RC",,,,,"facility","inpatient",,,,"4200","4200",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS HEMOFILTRATION","50000000","CDM","801","RC",,,,,"facility","outpatient",,,,"4200","4200",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMODIALYSIS INPATIENT","50000001","CDM","801","RC",,,,,"facility","inpatient",,,,"4440","4440",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEMODIALYSIS INPATIENT","50000001","CDM","801","RC",,,,,"facility","outpatient",,,,"4440","4440",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS PERITONEAL NON CAPD IP","50000002","CDM","802","RC",,,,,"facility","inpatient",,,,"1251","1251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS PERITONEAL NON CAPD IP","50000002","CDM","802","RC",,,,,"facility","outpatient",,,,"1251","1251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAPD INPATIENT","50000003","CDM","803","RC",,,,,"facility","inpatient",,,,"803","803",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CAPD INPATIENT","50000003","CDM","803","RC",,,,,"facility","outpatient",,,,"803","803",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCPD INPATIENT","50000004","CDM","804","RC",,,,,"facility","inpatient",,,,"2686","2686",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCPD INPATIENT","50000004","CDM","804","RC",,,,,"facility","outpatient",,,,"2686","2686",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS TX EMERGENCY OUTPATIENT","50000013","CDM","829","RC","G0257","HCPCS",,,"facility","inpatient",,,,"2314","2314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS TX EMERGENCY OUTPATIENT","50000013","CDM","829","RC","G0257","HCPCS",,,"facility","outpatient",,,,"2314","2314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTICAPHERESIS SELECTIVE","50000014","CDM","940","RC","36516","HCPCS",,,"facility","inpatient",,,,"13958","13958",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTICAPHERESIS SELECTIVE","50000014","CDM","940","RC","36516","HCPCS",,,"facility","outpatient",,,,"13958","13958",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC APHERESIS WBC","50000015","CDM","940","RC","36511","HCPCS",,,"facility","inpatient",,,,"7146","7146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC APHERESIS WBC","50000015","CDM","940","RC","36511","HCPCS",,,"facility","outpatient",,,,"7146","7146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC APHERESIS RBC","50000016","CDM","940","RC","36512","HCPCS",,,"facility","inpatient",,,,"15095","15095",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC APHERESIS RBC","50000016","CDM","940","RC","36512","HCPCS",,,"facility","outpatient",,,,"15095","15095",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC APHERESIS PLASMA","50000017","CDM","940","RC","36514","HCPCS",,,"facility","inpatient",,,,"7885","7885",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC APHERESIS PLASMA","50000017","CDM","940","RC","36514","HCPCS",,,"facility","outpatient",,,,"7885","7885",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC APHERESIS PLATELET","50000018","CDM","940","RC","36513","HCPCS",,,"facility","inpatient",,,,"14823","14823",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC APHERESIS PLATELET","50000018","CDM","940","RC","36513","HCPCS",,,"facility","outpatient",,,,"14823","14823",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS PRITONEAL OUTPATIENT","50000058","CDM","839","RC","90945","HCPCS",,,"facility","inpatient",,,,"2409","2409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS PRITONEAL OUTPATIENT","50000058","CDM","839","RC","90945","HCPCS",,,"facility","outpatient",,,,"2409","2409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS CONTINUOUS AMB PERITONEAL CAPD OP","50000059","CDM","849","RC","90945","HCPCS",,,"facility","inpatient",,,,"2409","2409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS CONTINUOUS AMB PERITONEAL CAPD OP","50000059","CDM","849","RC","90945","HCPCS",,,"facility","outpatient",,,,"2409","2409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS CONTINUOUS CYCLING PERITONEAL OP","50000060","CDM","859","RC","90945","HCPCS",,,"facility","inpatient",,,,"2409","2409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIALYSIS CONTINUOUS CYCLING PERITONEAL OP","50000060","CDM","859","RC","90945","HCPCS",,,"facility","outpatient",,,,"2409","2409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION HYDRATION INITIAL UP TO 1 HR","52000001","CDM","260","RC","96360","HCPCS",,,"facility","inpatient",,,,"1160","1160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION HYDRATION INITIAL UP TO 1 HR","52000001","CDM","260","RC","96360","HCPCS",,,"facility","outpatient",,,,"1160","1160",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION HYDRATION EA ADDL HR","52000002","CDM","260","RC","96361","HCPCS",,,"facility","inpatient",,,,"490","490",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION HYDRATION EA ADDL HR","52000002","CDM","260","RC","96361","HCPCS",,,"facility","outpatient",,,,"490","490",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION INITIAL W/MED UP TO 1 HR","52000003","CDM","260","RC","96365","HCPCS",,,"facility","inpatient",,,,"1214","1214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION INITIAL W/MED UP TO 1 HR","52000003","CDM","260","RC","96365","HCPCS",,,"facility","outpatient",,,,"1214","1214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION W/MED EA ADDL HR","52000004","CDM","260","RC","96366","HCPCS",,,"facility","inpatient",,,,"589","589",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION W/MED EA ADDL HR","52000004","CDM","260","RC","96366","HCPCS",,,"facility","outpatient",,,,"589","589",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION SEQ W MED UP TO 1 HR","52000005","CDM","260","RC","96367","HCPCS",,,"facility","inpatient",,,,"549","549",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION SEQ W MED UP TO 1 HR","52000005","CDM","260","RC","96367","HCPCS",,,"facility","outpatient",,,,"549","549",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION PORTABLE/IMPLANTED PUMP","52000006","CDM","260","RC","C8957","HCPCS",,,"facility","inpatient",,,,"740","740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION PORTABLE/IMPLANTED PUMP","52000006","CDM","260","RC","C8957","HCPCS",,,"facility","outpatient",,,,"740","740",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TRANSFUSION <=2 HRS","52000007","CDM","391","RC","36430","HCPCS",,,"facility","inpatient",,,,"857","857",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TRANSFUSION <=2 HRS","52000007","CDM","391","RC","36430","HCPCS",,,"facility","outpatient",,,,"857","857",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION IM/SQ EA","52000008","CDM","260","RC","96372","HCPCS",,,"facility","inpatient",,,,"345","345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION IM/SQ EA","52000008","CDM","260","RC","96372","HCPCS",,,"facility","outpatient",,,,"345","345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO NON-HORMONAL SQ/IM","52000010","CDM","331","RC","96401","HCPCS",,,"facility","inpatient",,,,"715","715",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO NON-HORMONAL SQ/IM","52000010","CDM","331","RC","96401","HCPCS",,,"facility","outpatient",,,,"715","715",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO HORMONAL SQ/IM","52000011","CDM","331","RC","96402","HCPCS",,,"facility","inpatient",,,,"533","533",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO HORMONAL SQ/IM","52000011","CDM","331","RC","96402","HCPCS",,,"facility","outpatient",,,,"533","533",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION PORTABLE/IMPLANTED PUMP","52000012","CDM","335","RC","96416","HCPCS",,,"facility","inpatient",,,,"1821","1821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION PORTABLE/IMPLANTED PUMP","52000012","CDM","335","RC","96416","HCPCS",,,"facility","outpatient",,,,"1821","1821",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO IA PUSH","52000013","CDM","331","RC","96420","HCPCS",,,"facility","inpatient",,,,"1789","1789",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO IA PUSH","52000013","CDM","331","RC","96420","HCPCS",,,"facility","outpatient",,,,"1789","1789",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION IA UP TO 1 HR","52000014","CDM","335","RC","96422","HCPCS",,,"facility","inpatient",,,,"1569","1569",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION IA UP TO 1 HR","52000014","CDM","335","RC","96422","HCPCS",,,"facility","outpatient",,,,"1569","1569",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION IA EA ADDL HR","52000015","CDM","335","RC","96423","HCPCS",,,"facility","inpatient",,,,"882","882",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION IA EA ADDL HR","52000015","CDM","335","RC","96423","HCPCS",,,"facility","outpatient",,,,"882","882",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REFILL PORTABLE PUMP","52000017","CDM","510","RC","96521","HCPCS",,,"facility","inpatient",,,,"749","749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REFILL PORTABLE PUMP","52000017","CDM","510","RC","96521","HCPCS",,,"facility","outpatient",,,,"749","749",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REFILL IMPLANTED PUMP","52000018","CDM","940","RC","96522","HCPCS",,,"facility","inpatient",,,,"913","913",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REFILL IMPLANTED PUMP","52000018","CDM","940","RC","96522","HCPCS",,,"facility","outpatient",,,,"913","913",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRRIG IMPLNTD VNS ACC DVC","52000019","CDM","940","RC","96523","HCPCS",,,"facility","inpatient",,,,"380","380",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRRIG IMPLNTD VNS ACC DVC","52000019","CDM","940","RC","96523","HCPCS",,,"facility","outpatient",,,,"380","380",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO SUBARACHNOID OR INTRAVENTRICULAR VIA SUBCUTANEOUS PUMP","52000020","CDM","331","RC","96542","HCPCS",,,"facility","inpatient",,,,"1602","1602",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO SUBARACHNOID OR INTRAVENTRICULAR VIA SUBCUTANEOUS PUMP","52000020","CDM","331","RC","96542","HCPCS",,,"facility","outpatient",,,,"1602","1602",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC PHLEBOTOMY","52000021","CDM","940","RC","99195","HCPCS",,,"facility","inpatient",,,,"646","646",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THERAPEUTIC PHLEBOTOMY","52000021","CDM","940","RC","99195","HCPCS",,,"facility","outpatient",,,,"646","646",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO IV PUSH ADDL NEW DRUG","52000022","CDM","331","RC","96411","HCPCS",,,"facility","inpatient",,,,"812","812",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO IV PUSH ADDL NEW DRUG","52000022","CDM","331","RC","96411","HCPCS",,,"facility","outpatient",,,,"812","812",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION SEQ UP TO 1 HR","52000023","CDM","335","RC","96417","HCPCS",,,"facility","inpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION SEQ UP TO 1 HR","52000023","CDM","335","RC","96417","HCPCS",,,"facility","outpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION EA ADDL HR","52000024","CDM","335","RC","96415","HCPCS",,,"facility","inpatient",,,,"684","684",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION EA ADDL HR","52000024","CDM","335","RC","96415","HCPCS",,,"facility","outpatient",,,,"684","684",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION IVP ADDL SEQ NEW DRG","52000025","CDM","260","RC","96375","HCPCS",,,"facility","inpatient",,,,"484","484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJECTION IVP ADDL SEQ NEW DRG","52000025","CDM","260","RC","96375","HCPCS",,,"facility","outpatient",,,,"484","484",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO IV PUSH INITIAL DRUG","52000026","CDM","331","RC","96409","HCPCS",,,"facility","inpatient",,,,"1155","1155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO IV PUSH INITIAL DRUG","52000026","CDM","331","RC","96409","HCPCS",,,"facility","outpatient",,,,"1155","1155",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION INITIAL UP TO 1 HR","52000027","CDM","335","RC","96413","HCPCS",,,"facility","inpatient",,,,"1768","1768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INFUSION INITIAL UP TO 1 HR","52000027","CDM","335","RC","96413","HCPCS",,,"facility","outpatient",,,,"1768","1768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IV PUSH INITIAL DRUG","52000031","CDM","260","RC","96374","HCPCS",,,"facility","inpatient",,,,"647","647",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IV PUSH INITIAL DRUG","52000031","CDM","260","RC","96374","HCPCS",,,"facility","outpatient",,,,"647","647",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO EXTEND IV INFUS W/PUMP","52000032","CDM","335","RC","G0498","HCPCS",,,"facility","inpatient",,,,"1338","1338",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO EXTEND IV INFUS W/PUMP","52000032","CDM","335","RC","G0498","HCPCS",,,"facility","outpatient",,,,"1338","1338",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION SUBCUT UP TO 1 HR","52000033","CDM","260","RC","96369","HCPCS",,,"facility","inpatient",,,,"522","522",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION SUBCUT UP TO 1 HR","52000033","CDM","260","RC","96369","HCPCS",,,"facility","outpatient",,,,"522","522",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION/POST ADMIN MONIT BAMLANIVIMAB","52000034","CDM","771","RC","M0239","HCPCS",,,"facility","outpatient",,,,"1261","1261",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION SUBCUT ADDL HR","52000035","CDM","260","RC","96370","HCPCS",,,"facility","inpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION SUBCUT ADDL HR","52000035","CDM","260","RC","96370","HCPCS",,,"facility","outpatient",,,,"154","154",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION SUBCUT RESET PUMP","52000037","CDM","260","RC","96371","HCPCS",,,"facility","inpatient",,,,"1197","1197",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION SUBCUT RESET PUMP","52000037","CDM","260","RC","96371","HCPCS",,,"facility","outpatient",,,,"1197","1197",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IVP SAME DRG EACH ADD (ELAPSED TIME >30M)","52000038","CDM","940","RC","96376","HCPCS",,,"facility","inpatient",,,,"469","469",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IVP SAME DRG EACH ADD (ELAPSED TIME >30M)","52000038","CDM","940","RC","96376","HCPCS",,,"facility","outpatient",,,,"469","469",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION CONCURRENT","52000039","CDM","260","RC","96368","HCPCS",,,"facility","inpatient",,,,"489","489",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION CONCURRENT","52000039","CDM","260","RC","96368","HCPCS",,,"facility","outpatient",,,,"489","489",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TRANSFUSION 2-4 HRS","52000041","CDM","391","RC","36430","HCPCS",,,"facility","inpatient",,,,"1713","1713",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TRANSFUSION 2-4 HRS","52000041","CDM","391","RC","36430","HCPCS",,,"facility","outpatient",,,,"1713","1713",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TRANSFUSION 4-6 HRS","52000042","CDM","391","RC","36430","HCPCS",,,"facility","inpatient",,,,"2570","2570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TRANSFUSION 4-6 HRS","52000042","CDM","391","RC","36430","HCPCS",,,"facility","outpatient",,,,"2570","2570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TRANSFUSION > 6 HRS","52000043","CDM","391","RC","36430","HCPCS",,,"facility","inpatient",,,,"3426","3426",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLOOD TRANSFUSION > 6 HRS","52000043","CDM","391","RC","36430","HCPCS",,,"facility","outpatient",,,,"3426","3426",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLICATON ON-BODY INJECTOR","52010021","CDM","260","RC","96377","HCPCS",,,"facility","inpatient",,,,"338","338",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLICATON ON-BODY INJECTOR","52010021","CDM","260","RC","96377","HCPCS",,,"facility","outpatient",,,,"338","338",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INTRALESIONAL UP TO 7","52010022","CDM","331","RC","96405","HCPCS",,,"facility","inpatient",,,,"335","335",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO INTRALESIONAL UP TO 7","52010022","CDM","331","RC","96405","HCPCS",,,"facility","outpatient",,,,"335","335",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED PROCEDURE MAJOR","55000000","CDM","450","RC",,,,,"facility","inpatient",,,,"1604","1604",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED PROCEDURE MAJOR","55000000","CDM","450","RC",,,,,"facility","outpatient",,,,"1604","1604",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED PROCEDURE MINOR","55000001","CDM","450","RC",,,,,"facility","inpatient",,,,"666","666",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED PROCEDURE MINOR","55000001","CDM","450","RC",,,,,"facility","outpatient",,,,"666","666",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 1","55000005","CDM","450","RC","99281","HCPCS",,,"facility","inpatient",,,,"603","603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 1","55000005","CDM","450","RC","99281","HCPCS",,,"facility","outpatient",,,,"603","603",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 2","55000007","CDM","450","RC","99282","HCPCS",,,"facility","inpatient",,,,"1527","1527",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 2","55000007","CDM","450","RC","99282","HCPCS",,,"facility","outpatient",,,,"1527","1527",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 3","55000008","CDM","450","RC","99283","HCPCS",,,"facility","inpatient",,,,"3093","3093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 3","55000008","CDM","450","RC","99283","HCPCS",,,"facility","outpatient",,,,"3093","3093",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 4","55000010","CDM","450","RC","99284","HCPCS",,,"facility","inpatient",,,,"5214","5214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 4","55000010","CDM","450","RC","99284","HCPCS",,,"facility","outpatient",,,,"5214","5214",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 5","55000012","CDM","450","RC","99285","HCPCS",,,"facility","inpatient",,,,"8003","8003",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED LEVEL 5","55000012","CDM","450","RC","99285","HCPCS",,,"facility","outpatient",,,,"8003","8003",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED CRIT CARE 1ST 30-74 MN","55000015","CDM","450","RC","99291","HCPCS",,,"facility","inpatient",,,,"9840","9840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED CRIT CARE 1ST 30-74 MN","55000015","CDM","450","RC","99291","HCPCS",,,"facility","outpatient",,,,"9840","9840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED CRIT CARE ADD 30 MIN","55000017","CDM","450","RC","99292","HCPCS",,,"facility","inpatient",,,,"3745","3745",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED CRIT CARE ADD 30 MIN","55000017","CDM","450","RC","99292","HCPCS",,,"facility","outpatient",,,,"3745","3745",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPECAC/CHARCOAL ADMINISTRATION","55000023","CDM","940","RC","99175","HCPCS",,,"facility","inpatient",,,,"395","395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IPECAC/CHARCOAL ADMINISTRATION","55000023","CDM","940","RC","99175","HCPCS",,,"facility","outpatient",,,,"395","395",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SCRN VISUAL ACTY QN BIL","55000026","CDM","450","RC","99173","HCPCS",,,"facility","inpatient",,,"GY","41","41",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG SCRN VISUAL ACTY QN BIL","55000026","CDM","450","RC","99173","HCPCS",,,"facility","outpatient",,,"GY","41","41",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG VENIPUNCTURE <3 YEARS OTHER VEIN","55000028","CDM","450","RC","36406","HCPCS",,,"facility","inpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE <3 YEARS OTHER VEIN","55000028","CDM","450","RC","36406","HCPCS",,,"facility","outpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED CATH SPECIMEN COLL SGL PT","55000029","CDM","300","RC","P9612","HCPCS",,,"facility","inpatient",,,,"112","112",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED CATH SPECIMEN COLL SGL PT","55000029","CDM","300","RC","P9612","HCPCS",,,"facility","outpatient",,,,"134","134",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED COLL BLD PICC/CNTRL LN","55000030","CDM","450","RC","36592","HCPCS",,,"facility","inpatient",,,,"459","459",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED COLL BLD PICC/CNTRL LN","55000030","CDM","450","RC","36592","HCPCS",,,"facility","outpatient",,,,"459","459",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED COLL BLD IMP VEN ACCS DEV","55000031","CDM","450","RC","36591","HCPCS",,,"facility","inpatient",,,,"381","381",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED COLL BLD IMP VEN ACCS DEV","55000031","CDM","450","RC","36591","HCPCS",,,"facility","outpatient",,,,"381","381",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ED CC 1ST 30-74 MN W/PROC","55000032","CDM","450","RC","99291","HCPCS",,,"facility","inpatient",,,"25","9840","9840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED CC 1ST 30-74 MN W/PROC","55000032","CDM","450","RC","99291","HCPCS",,,"facility","outpatient",,,"25","9840","9840",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 1 W/PROC","55000033","CDM","450","RC","99281","HCPCS",,,"facility","inpatient",,,"25","603","603",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 1 W/PROC","55000033","CDM","450","RC","99281","HCPCS",,,"facility","outpatient",,,"25","603","603",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 2 W/PROC","55000034","CDM","450","RC","99282","HCPCS",,,"facility","inpatient",,,"25","1527","1527",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 2 W/PROC","55000034","CDM","450","RC","99282","HCPCS",,,"facility","outpatient",,,"25","1527","1527",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 3 W/PROC","55000035","CDM","450","RC","99283","HCPCS",,,"facility","inpatient",,,"25","3093","3093",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 3 W/PROC","55000035","CDM","450","RC","99283","HCPCS",,,"facility","outpatient",,,"25","3093","3093",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 4 W/PROC","55000036","CDM","450","RC","99284","HCPCS",,,"facility","inpatient",,,"25","5214","5214",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 4 W/PROC","55000036","CDM","450","RC","99284","HCPCS",,,"facility","outpatient",,,"25","5214","5214",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 5 W/PROC","55000037","CDM","450","RC","99285","HCPCS",,,"facility","inpatient",,,"25","8003","8003",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ED LEVEL 5 W/PROC","55000037","CDM","450","RC","99285","HCPCS",,,"facility","outpatient",,,"25","8003","8003",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG ART CATH MNTRNG PERC","55000053","CDM","450","RC","36620","HCPCS",,,"facility","inpatient",,,,"1493","1493",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ART CATH MNTRNG PERC","55000053","CDM","450","RC","36620","HCPCS",,,"facility","outpatient",,,,"1493","1493",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCC BLD 1-3 SPC NO NPLSM","55000054","CDM","301","RC","82272","HCPCS",,,"facility","inpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCC BLD 1-3 SPC NO NPLSM","55000054","CDM","301","RC","82272","HCPCS",,,"facility","outpatient",,,,"120","120",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPR","55000055","CDM","450","RC","92950","HCPCS",,,"facility","inpatient",,,,"1397","1397",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPR","55000055","CDM","450","RC","92950","HCPCS",,,"facility","outpatient",,,,"1397","1397",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TEMP TRANSCUTANEOUS PACING","55000056","CDM","450","RC","92953","HCPCS",,,"facility","inpatient",,,,"1825","1825",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TEMP TRANSCUTANEOUS PACING","55000056","CDM","450","RC","92953","HCPCS",,,"facility","outpatient",,,,"1825","1825",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOVERSION ELECTRIC EXTERNAL","55000057","CDM","450","RC","92960","HCPCS",,,"facility","inpatient",,,,"2268","2268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARDIOVERSION ELECTRIC EXTERNAL","55000057","CDM","450","RC","92960","HCPCS",,,"facility","outpatient",,,,"2268","2268",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SLIT LAMP PROCEDURE","55000066","CDM","450","RC","92285","HCPCS",,,"facility","inpatient",,,,"586","586",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SLIT LAMP PROCEDURE","55000066","CDM","450","RC","92285","HCPCS",,,"facility","outpatient",,,,"586","586",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ARTERIAL PUNCTURE","55000068","CDM","450","RC","36600","HCPCS",,,"facility","inpatient",,,,"345","345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ARTERIAL PUNCTURE","55000068","CDM","450","RC","36600","HCPCS",,,"facility","outpatient",,,,"345","345",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE AGE 3 YRS/>","55000069","CDM","450","RC","36410","HCPCS",,,"facility","inpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VENIPUNCTURE AGE 3 YRS/>","55000069","CDM","450","RC","36410","HCPCS",,,"facility","outpatient",,,,"75","75",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NT CATHETER SX/ASPIRATION","55000070","CDM","450","RC","31720","HCPCS",,,"facility","inpatient",,,,"404","404",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NT CATHETER SX/ASPIRATION","55000070","CDM","450","RC","31720","HCPCS",,,"facility","outpatient",,,,"404","404",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT WHFO RIGID NO JNTS CUSTOM F/A INHOUSE","64000052","CDM","274","RC","L3808","HCPCS",,,"facility","inpatient",,,,"644","644",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT WHFO RIGID NO JNTS CUSTOM F/A INHOUSE","64000052","CDM","274","RC","L3808","HCPCS",,,"facility","outpatient",,,,"644","644",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT WHO NO JOINTS CUSTOM F/A INHOUSE","64000068","CDM","274","RC","L3906","HCPCS",,,"facility","inpatient",,,,"497","497",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT WHO NO JOINTS CUSTOM F/A INHOUSE","64000068","CDM","274","RC","L3906","HCPCS",,,"facility","outpatient",,,,"497","497",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT AFO PLASTIC/OTHER CUSTOM INHOUSE","64000105","CDM","274","RC","L1940","HCPCS",,,"facility","inpatient",,,,"624","624",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT AFO PLASTIC/OTHER CUSTOM INHOUSE","64000105","CDM","274","RC","L1940","HCPCS",,,"facility","outpatient",,,,"624","624",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PR KNEE LOCKING JT PF","64000120","CDM","274","RC","L1831","HCPCS",,,"facility","inpatient",,,,"624","624",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PR KNEE LOCKING JT PF","64000120","CDM","274","RC","L1831","HCPCS",,,"facility","outpatient",,,,"624","624",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EO WO JNTS STRAP CUSTOM F/A INHOUSE","64000163","CDM","274","RC","L3702","HCPCS",,,"facility","inpatient",,,,"264","264",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EO WO JNTS STRAP CUSTOM F/A INHOUSE","64000163","CDM","274","RC","L3702","HCPCS",,,"facility","outpatient",,,,"264","264",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EWHO RIGID WO JNTS CUSTOM F/A INHOUSE","64000164","CDM","274","RC","L3763","HCPCS",,,"facility","inpatient",,,,"1173","1173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EWHO RIGID WO JNTS CUSTOM F/A INHOUSE","64000164","CDM","274","RC","L3763","HCPCS",,,"facility","outpatient",,,,"1173","1173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EWHFO JNTS BND BKLS CUSTOM F/A INHOUSE","64000165","CDM","274","RC","L3766","HCPCS",,,"facility","inpatient",,,,"1243","1243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EWHFO JNTS BND BKLS CUSTOM F/A INHOUSE","64000165","CDM","274","RC","L3766","HCPCS",,,"facility","outpatient",,,,"1243","1243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT WHO JNTS BND BKL CUSTOM F/A INHOUSE","64000166","CDM","274","RC","L3905","HCPCS",,,"facility","inpatient",,,,"908","908",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT WHO JNTS BND BKL CUSTOM F/A INHOUSE","64000166","CDM","274","RC","L3905","HCPCS",,,"facility","outpatient",,,,"908","908",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT HFO WO JOINTS CUSTOM F/A INHOUSE","64000167","CDM","274","RC","L3913","HCPCS",,,"facility","inpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT HFO WO JOINTS CUSTOM F/A INHOUSE","64000167","CDM","274","RC","L3913","HCPCS",,,"facility","outpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT HO WO JOINTS CUSTOM F/A INHOUSE","64000168","CDM","274","RC","L3919","HCPCS",,,"facility","inpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT HO WO JOINTS CUSTOM F/A INHOUSE","64000168","CDM","274","RC","L3919","HCPCS",,,"facility","outpatient",,,,"248","248",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT HFO JNTS BNDS BKLS CUSTOM F/A INHOUSE","64000169","CDM","274","RC","L3921","HCPCS",,,"facility","inpatient",,,,"293","293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT HFO JNTS BNDS BKLS CUSTOM F/A INHOUSE","64000169","CDM","274","RC","L3921","HCPCS",,,"facility","outpatient",,,,"293","293",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SO AIRPLANE W/WO JOINT CUSTOM F/A INHOUSE","64000268","CDM","274","RC","L3674","HCPCS",,,"facility","inpatient",,,,"981","981",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SO AIRPLANE W/WO JOINT CUSTOM F/A INHOUSE","64000268","CDM","274","RC","L3674","HCPCS",,,"facility","outpatient",,,,"981","981",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KO WO JOINT RIGID CUSTOM INHOUSE","64000269","CDM","274","RC","L1834","HCPCS",,,"facility","inpatient",,,,"855","855",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG KO WO JOINT RIGID CUSTOM INHOUSE","64000269","CDM","274","RC","L1834","HCPCS",,,"facility","outpatient",,,,"855","855",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT FINGER W JOINT CUSTOM F/A INHOUSE","64000309","CDM","274","RC","L3935","HCPCS",,,"facility","inpatient",,,,"196","196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT FINGER W JOINT CUSTOM F/A INHOUSE","64000309","CDM","274","RC","L3935","HCPCS",,,"facility","outpatient",,,,"196","196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EWHO W/JNTS BND BKL CUSTOM F/A INHOUSE","64000322","CDM","274","RC","L3764","HCPCS",,,"facility","inpatient",,,,"1243","1243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EWHO W/JNTS BND BKL CUSTOM F/A INHOUSE","64000322","CDM","274","RC","L3764","HCPCS",,,"facility","outpatient",,,,"1243","1243",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EWHFO RGD WO JNT STRP CUSTOM F/A INHOUSE","64000323","CDM","274","RC","L3765","HCPCS",,,"facility","inpatient",,,,"1173","1173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT EWHFO RGD WO JNT STRP CUSTOM F/A INHOUSE","64000323","CDM","274","RC","L3765","HCPCS",,,"facility","outpatient",,,,"1173","1173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT SEWHO AIRPLANE WO JNTS CUSTOM F/A INHOUSE","64000325","CDM","274","RC","L3967","HCPCS",,,"facility","inpatient",,,,"1816","1816",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT SEWHO AIRPLANE WO JNTS CUSTOM F/A INHOUSE","64000325","CDM","274","RC","L3967","HCPCS",,,"facility","outpatient",,,,"1816","1816",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT SEWHO AIRPLANE W JNTS CUSTOM F/A INHOUSE","64000326","CDM","274","RC","L3973","HCPCS",,,"facility","inpatient",,,,"1816","1816",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT SEWHO AIRPLANE W JNTS CUSTOM F/A INHOUSE","64000326","CDM","274","RC","L3973","HCPCS",,,"facility","outpatient",,,,"1816","1816",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRACHY SRC HDR IR192","67000769","CDM","278","RC","C1717","HCPCS",,,"facility","inpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRACHY SRC HDR IR192","67000769","CDM","278","RC","C1717","HCPCS",,,"facility","outpatient",,,,"685","685",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT WHFO JNTS BND SPRNG CUSTOM F/A INHOUSE","67002170","CDM","274","RC","L3806","HCPCS",,,"facility","inpatient",,,,"416","416",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT WHFO JNTS BND SPRNG CUSTOM F/A INHOUSE","67002170","CDM","274","RC","L3806","HCPCS",,,"facility","outpatient",,,,"416","416",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT FINGER WO JNTS CUSTOM F/A INHOUSE","67002171","CDM","274","RC","L3933","HCPCS",,,"facility","inpatient",,,,"196","196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT FINGER WO JNTS CUSTOM F/A INHOUSE","67002171","CDM","274","RC","L3933","HCPCS",,,"facility","outpatient",,,,"196","196",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT SEWHO AIRPLANE WO JNTS CUSTOM F/A INHOUSE","67002172","CDM","274","RC","L3976","HCPCS",,,"facility","inpatient",,,,"1537","1537",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OT SEWHO AIRPLANE WO JNTS CUSTOM F/A INHOUSE","67002172","CDM","274","RC","L3976","HCPCS",,,"facility","outpatient",,,,"1537","1537",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C14 FOR UREA TEST","68000000","CDM","343","RC","A4641","HCPCS",,,"facility","inpatient",,,,"567","567",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG C14 FOR UREA TEST","68000000","CDM","343","RC","A4641","HCPCS",,,"facility","outpatient",,,,"567","567",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP IOBENGAN I123 DX 15MCI","68000001","CDM","343","RC","A9582","HCPCS",,,"facility","inpatient",,,,"2578","2578",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP IOBENGAN I123 DX 15MCI","68000001","CDM","343","RC","A9582","HCPCS",,,"facility","outpatient",,,,"2578","2578",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SM 153 LEXIDRONAM 150MCI","68000002","CDM","344","RC","A9604","HCPCS",,,"facility","inpatient",,,,"13510","13510",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SM 153 LEXIDRONAM 150MCI","68000002","CDM","344","RC","A9604","HCPCS",,,"facility","outpatient",,,,"13510","13510",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDIUM IN-111 LABELED AUTOLOGOUS WBC DX STUDY","68000005","CDM","343","RC","A9570","HCPCS",,,"facility","inpatient",,,,"7260","7260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDIUM IN-111 LABELED AUTOLOGOUS WBC DX STUDY","68000005","CDM","343","RC","A9570","HCPCS",,,"facility","outpatient",,,,"7260","7260",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLORBETAPIR F18","68000007","CDM","343","RC","A9586","HCPCS",,,"facility","inpatient",,,,"8118","8118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLORBETAPIR F18","68000007","CDM","343","RC","A9586","HCPCS",,,"facility","outpatient",,,,"8118","8118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP TECHNETIUM TC99M AUTO WBC","68000008","CDM","343","RC","A9569","HCPCS",,,"facility","inpatient",,,,"5040","5040",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP TECHNETIUM TC99M AUTO WBC","68000008","CDM","343","RC","A9569","HCPCS",,,"facility","outpatient",,,,"5040","5040",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RADIUM RA 223 DICHLORIDE TX XOFIGO PER UCI","68000009","CDM","344","RC","A9606","HCPCS",,,"facility","inpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RADIUM RA 223 DICHLORIDE TX XOFIGO PER UCI","68000009","CDM","344","RC","A9606","HCPCS",,,"facility","outpatient",,,,"350","350",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TECHNETIUM TC 99M TILMANOCEPT DX 0.5 MCI","68000010","CDM","343","RC","A9520","HCPCS",,,"facility","inpatient",,,,"1274","1274",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TECHNETIUM TC 99M TILMANOCEPT DX 0.5 MCI","68000010","CDM","343","RC","A9520","HCPCS",,,"facility","outpatient",,,,"1274","1274",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLORBETABEN F18 DX PER STUDY TO 8.1 MCI","68000016","CDM","343","RC","Q9983","HCPCS",,,"facility","inpatient",,,,"8118","8118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLORBETABEN F18 DX PER STUDY TO 8.1 MCI","68000016","CDM","343","RC","Q9983","HCPCS",,,"facility","outpatient",,,,"8118","8118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GALLIUM GA-68 DOTATATE DX 0.1 MCI","68000019","CDM","343","RC","A9587","HCPCS",,,"facility","inpatient",,,,"167","167",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GALLIUM GA-68 DOTATATE DX 0.1 MCI","68000019","CDM","343","RC","A9587","HCPCS",,,"facility","outpatient",,,,"167","167",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUCICLOVINE F-18 DX 1 MCI","68000020","CDM","343","RC","A9588","HCPCS",,,"facility","inpatient",,,,"974","974",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUCICLOVINE F-18 DX 1 MCI","68000020","CDM","343","RC","A9588","HCPCS",,,"facility","outpatient",,,,"974","974",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TECHNETIUM TC99M AEROSOL =< 75 MCI","68000021","CDM","343","RC","A9567","HCPCS",,,"facility","inpatient",,,,"381","381",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TECHNETIUM TC99M AEROSOL =< 75 MCI","68000021","CDM","343","RC","A9567","HCPCS",,,"facility","outpatient",,,,"381","381",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUTETIUM LU 177 DOTATATE TX 1 MCI","68000024","CDM","344","RC","A9513","HCPCS",,,"facility","inpatient",,,,"648","648",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUTETIUM LU 177 DOTATATE TX 1 MCI","68000024","CDM","344","RC","A9513","HCPCS",,,"facility","outpatient",,,,"648","648",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUOROESTRADIOL F18 DX 1 MCI","68000028","CDM","343","RC","A9591","HCPCS",,,"facility","inpatient",,,,"1954","1954",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUOROESTRADIOL F18 DX 1 MCI","68000028","CDM","343","RC","A9591","HCPCS",,,"facility","outpatient",,,,"1954","1954",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COPPER CU-64 DOTATATE DX 1 MCI","68000031","CDM","343","RC","A9592","HCPCS",,,"facility","inpatient",,,,"2321","2321",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COPPER CU-64 DOTATATE DX 1 MCI","68000031","CDM","343","RC","A9592","HCPCS",,,"facility","outpatient",,,,"2321","2321",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PIFLUFOLASTAT F18 (PYLARIFY) DX 1 MCI","68000033","CDM","343","RC","A9595","HCPCS",,,"facility","inpatient",,,,"1263","1263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PIFLUFOLASTAT F18 (PYLARIFY) DX 1 MCI","68000033","CDM","343","RC","A9595","HCPCS",,,"facility","outpatient",,,,"1263","1263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUTETIUM LU 177 VIPIVOTIDE 1 MCI","68000034","CDM","344","RC","A9607","HCPCS",,,"facility","inpatient",,,,"450","450",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUTETIUM LU 177 VIPIVOTIDE 1 MCI","68000034","CDM","344","RC","A9607","HCPCS",,,"facility","outpatient",,,,"450","450",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLOTUFOLASTAT F18 DX 1 MCI","68000035","CDM","343","RC","A9608","HCPCS",,,"facility","inpatient",,,,"2216","2216",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLOTUFOLASTAT F18 DX 1 MCI","68000035","CDM","343","RC","A9608","HCPCS",,,"facility","outpatient",,,,"2216","2216",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUDIOXYGLUCOSE F18 DX UP TO 15 MCI","68000036","CDM","343","RC","A9609","HCPCS",,,"facility","inpatient",,,,"213","213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUDIOXYGLUCOSE F18 DX UP TO 15 MCI","68000036","CDM","343","RC","A9609","HCPCS",,,"facility","outpatient",,,,"213","213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GALLIUM ILLUCCIX 1 MILLICURE","68000039","CDM","343","RC","A9596","HCPCS",,,"facility","inpatient",,,,"2594","2594",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GALLIUM ILLUCCIX 1 MILLICURE","68000039","CDM","343","RC","A9596","HCPCS",,,"facility","outpatient",,,,"2594","2594",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-123 MIBG PER DOSE","68000050","CDM","343","RC","A4641","HCPCS",,,"facility","inpatient",,,,"7121","7121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-123 MIBG PER DOSE","68000050","CDM","343","RC","A4641","HCPCS",,,"facility","outpatient",,,,"7121","7121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-125 PER 10UCI","68000100","CDM","343","RC","A4641","HCPCS",,,"facility","inpatient",,,,"1207","1207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-125 PER 10UCI","68000100","CDM","343","RC","A4641","HCPCS",,,"facility","outpatient",,,,"1207","1207",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M SESTAMIBI DIAGNOSTIC UP TO 40MC","68000300","CDM","343","RC","A9500","HCPCS",,,"facility","inpatient",,,,"545","545",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M SESTAMIBI DIAGNOSTIC UP TO 40MC","68000300","CDM","343","RC","A9500","HCPCS",,,"facility","outpatient",,,,"545","545",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M TETROFOSMIN DX PER STUDY DOSE","68000350","CDM","343","RC","A9502","HCPCS",,,"facility","inpatient",,,,"383","383",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M TETROFOSMIN DX PER STUDY DOSE","68000350","CDM","343","RC","A9502","HCPCS",,,"facility","outpatient",,,,"383","383",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M MEDRONATE DIAGNOSTIC 1 TO 30 MC","68000400","CDM","343","RC","A9503","HCPCS",,,"facility","inpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M MEDRONATE DIAGNOSTIC 1 TO 30 MC","68000400","CDM","343","RC","A9503","HCPCS",,,"facility","outpatient",,,,"217","217",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDIUM IN-111 PENTETREOTIDE DX STUDY UP TO 6 MCI","68000450","CDM","343","RC","A9572","HCPCS",,,"facility","inpatient",,,,"4939","4939",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDIUM IN-111 PENTETREOTIDE DX STUDY UP TO 6 MCI","68000450","CDM","343","RC","A9572","HCPCS",,,"facility","outpatient",,,,"4939","4939",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TL-201 THALLOUS CHLORIDE DIAGNOSTIC PER MCI","68000500","CDM","343","RC","A9505","HCPCS",,,"facility","inpatient",,,,"194","194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TL-201 THALLOUS CHLORIDE DIAGNOSTIC PER MCI","68000500","CDM","343","RC","A9505","HCPCS",,,"facility","outpatient",,,,"194","194",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN-111 PROSTASCINT DIAGNOSTIC UP TO 10","68000550","CDM","343","RC","A9507","HCPCS",,,"facility","inpatient",,,,"4081","4081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN-111 PROSTASCINT DIAGNOSTIC UP TO 10","68000550","CDM","343","RC","A9507","HCPCS",,,"facility","outpatient",,,,"4081","4081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-131 MIBG DIAGNOSTIC PER  O.5MCI","68000600","CDM","343","RC","A9508","HCPCS",,,"facility","inpatient",,,,"2182","2182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-131 MIBG DIAGNOSTIC PER  O.5MCI","68000600","CDM","343","RC","A9508","HCPCS",,,"facility","outpatient",,,,"2182","2182",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M PERTECHNETATE DIAGNOSTIC PER MC","68000700","CDM","343","RC","A9512","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M PERTECHNETATE DIAGNOSTIC PER MC","68000700","CDM","343","RC","A9512","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-123 SODIUM IODIDE DX CAP PER 100 UCI UP TO 999","68000800","CDM","343","RC","A9516","HCPCS",,,"facility","inpatient",,,,"270","270",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-123 SODIUM IODIDE DX CAP PER 100 UCI UP TO 999","68000800","CDM","343","RC","A9516","HCPCS",,,"facility","outpatient",,,,"270","270",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IODINE I-131 SODIUM IODIDE CAP(S) TX PER MCI","68000850","CDM","344","RC","A9517","HCPCS",,,"facility","inpatient",,,,"136","136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IODINE I-131 SODIUM IODIDE CAP(S) TX PER MCI","68000850","CDM","344","RC","A9517","HCPCS",,,"facility","outpatient",,,,"136","136",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC99M CERETEC DIAGNOSTIC UP TO 25MCI","68000900","CDM","343","RC","A9521","HCPCS",,,"facility","inpatient",,,,"1348","1348",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC99M CERETEC DIAGNOSTIC UP TO 25MCI","68000900","CDM","343","RC","A9521","HCPCS",,,"facility","outpatient",,,,"1348","1348",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IODINE I-131 SODIUM IODIDE CAP(S) DX PER MCI","68000950","CDM","343","RC","A9528","HCPCS",,,"facility","inpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IODINE I-131 SODIUM IODIDE CAP(S) DX PER MCI","68000950","CDM","343","RC","A9528","HCPCS",,,"facility","outpatient",,,,"118","118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IODINE I-131 SODIUM IODIDE SOLUTION TX PER MCI","68001050","CDM","344","RC","A9530","HCPCS",,,"facility","inpatient",,,,"56","56",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IODINE I-131 SODIUM IODIDE SOLUTION TX PER MCI","68001050","CDM","344","RC","A9530","HCPCS",,,"facility","outpatient",,,,"56","56",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M DEPREOTIDE DIAGNOSTIC UP TO 35MCI","68001100","CDM","343","RC","A9536","HCPCS",,,"facility","inpatient",,,,"3699","3699",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M DEPREOTIDE DIAGNOSTIC UP TO 35MCI","68001100","CDM","343","RC","A9536","HCPCS",,,"facility","outpatient",,,,"3699","3699",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M MEBROFENIN DIAGNOSTIC UP TO 15M","68001150","CDM","343","RC","A9537","HCPCS",,,"facility","inpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M MEBROFENIN DIAGNOSTIC UP TO 15M","68001150","CDM","343","RC","A9537","HCPCS",,,"facility","outpatient",,,,"275","275",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M PYROPHOSPHATE DIAGNOSTIC UP TO","68001200","CDM","343","RC","A9538","HCPCS",,,"facility","inpatient",,,,"150","150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M PYROPHOSPHATE DIAGNOSTIC UP TO","68001200","CDM","343","RC","A9538","HCPCS",,,"facility","outpatient",,,,"150","150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC99M PENTETATE DIAGNOSTIC UP TO 25MCI","68001250","CDM","343","RC","A9539","HCPCS",,,"facility","inpatient",,,,"241","241",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC99M PENTETATE DIAGNOSTIC UP TO 25MCI","68001250","CDM","343","RC","A9539","HCPCS",,,"facility","outpatient",,,,"241","241",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M MAA DIAGNOSTIC UP TO 10MCI","68001300","CDM","343","RC","A9540","HCPCS",,,"facility","inpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M MAA DIAGNOSTIC UP TO 10MCI","68001300","CDM","343","RC","A9540","HCPCS",,,"facility","outpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC99M SULFUR COLLOID DIAGNOSTIC UP TO","68001350","CDM","343","RC","A9541","HCPCS",,,"facility","inpatient",,,,"263","263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC99M SULFUR COLLOID DIAGNOSTIC UP TO","68001350","CDM","343","RC","A9541","HCPCS",,,"facility","outpatient",,,,"263","263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN-111 IBRITUMOMAB (ZEVALIN) DIAGNOSTI","68001400","CDM","343","RC","A9542","HCPCS",,,"facility","inpatient",,,,"4948","4948",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN-111 IBRITUMOMAB (ZEVALIN) DIAGNOSTI","68001400","CDM","343","RC","A9542","HCPCS",,,"facility","outpatient",,,,"4948","4948",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG Y-90 IBRITUMOMAB (ZEVALIN) THERAPEUTIC","68001450","CDM","344","RC","A9543","HCPCS",,,"facility","inpatient",,,,"88045","88045",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG Y-90 IBRITUMOMAB (ZEVALIN) THERAPEUTIC","68001450","CDM","344","RC","A9543","HCPCS",,,"facility","outpatient",,,,"88045","88045",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COBALT 57/58 DIAGNOSTIC UP TO 1UCI","68001600","CDM","343","RC","A9546","HCPCS",,,"facility","inpatient",,,,"964","964",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COBALT 57/58 DIAGNOSTIC UP TO 1UCI","68001600","CDM","343","RC","A9546","HCPCS",,,"facility","outpatient",,,,"964","964",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN-111 OXYQUINOLINE DX PER 0.5 MCI","68001650","CDM","343","RC","A9547","HCPCS",,,"facility","inpatient",,,,"2623","2623",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN-111 OXYQUINOLINE DX PER 0.5 MCI","68001650","CDM","343","RC","A9547","HCPCS",,,"facility","outpatient",,,,"2623","2623",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN-111 PENTETATE DIAGNOSTIC PER 0.5 MC","68001700","CDM","343","RC","A9548","HCPCS",,,"facility","inpatient",,,,"2304","2304",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IN-111 PENTETATE DIAGNOSTIC PER 0.5 MC","68001700","CDM","343","RC","A9548","HCPCS",,,"facility","outpatient",,,,"2304","2304",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99 GLUCEPTATE DIAGNOSTIC UP TO 25MC","68001750","CDM","343","RC","A9550","HCPCS",,,"facility","inpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99 GLUCEPTATE DIAGNOSTIC UP TO 25MC","68001750","CDM","343","RC","A9550","HCPCS",,,"facility","outpatient",,,,"133","133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99 SUCCIMER DIAGNOSTIC UP TO 10MCI","68001800","CDM","343","RC","A9551","HCPCS",,,"facility","inpatient",,,,"251","251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99 SUCCIMER DIAGNOSTIC UP TO 10MCI","68001800","CDM","343","RC","A9551","HCPCS",,,"facility","outpatient",,,,"251","251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG F-18 FDG DIAGNOSTIC UP TO 45MCI","68001850","CDM","343","RC","A9552","HCPCS",,,"facility","inpatient",,,,"1313","1313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG F-18 FDG DIAGNOSTIC UP TO 45MCI","68001850","CDM","343","RC","A9552","HCPCS",,,"facility","outpatient",,,,"1313","1313",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CR-51 CHROMATE DIAGNOSTIC UP TO 250UCI","68001900","CDM","343","RC","A9553","HCPCS",,,"facility","inpatient",,,,"717","717",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CR-51 CHROMATE DIAGNOSTIC UP TO 250UCI","68001900","CDM","343","RC","A9553","HCPCS",,,"facility","outpatient",,,,"717","717",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-125 IOTHALAMATE DIAGNOSTIC UP TO 10U","68001950","CDM","343","RC","A9554","HCPCS",,,"facility","inpatient",,,,"857","857",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I-125 IOTHALAMATE DIAGNOSTIC UP TO 10U","68001950","CDM","343","RC","A9554","HCPCS",,,"facility","outpatient",,,,"857","857",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GA-67 GALLIUM DIAGNOSTIC PER MCI","68002000","CDM","343","RC","A9556","HCPCS",,,"facility","inpatient",,,,"159","159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GA-67 GALLIUM DIAGNOSTIC PER MCI","68002000","CDM","343","RC","A9556","HCPCS",,,"facility","outpatient",,,,"159","159",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XE-133 XENON GAS DIAGNOSTIC PER 10MCI","68002100","CDM","343","RC","A9558","HCPCS",,,"facility","inpatient",,,,"338","338",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG XE-133 XENON GAS DIAGNOSTIC PER 10MCI","68002100","CDM","343","RC","A9558","HCPCS",,,"facility","outpatient",,,,"338","338",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M LABELED RBC DIAGNOSTIC UP TO 30","68002150","CDM","343","RC","A9560","HCPCS",,,"facility","inpatient",,,,"540","540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99M LABELED RBC DIAGNOSTIC UP TO 30","68002150","CDM","343","RC","A9560","HCPCS",,,"facility","outpatient",,,,"540","540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC99 OXIDRONATE DX 30MCI","68002200","CDM","343","RC","A9561","HCPCS",,,"facility","inpatient",,,,"179","179",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC99 OXIDRONATE DX 30MCI","68002200","CDM","343","RC","A9561","HCPCS",,,"facility","outpatient",,,,"179","179",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99 MERTIATIDE DIAGNOSTIC UP TO 15MC","68002250","CDM","343","RC","A9562","HCPCS",,,"facility","inpatient",,,,"805","805",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99 MERTIATIDE DIAGNOSTIC UP TO 15MC","68002250","CDM","343","RC","A9562","HCPCS",,,"facility","outpatient",,,,"805","805",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG P-32 SODIUM PHOSPHATE THERAPEUTIC PER","68002300","CDM","344","RC","A9563","HCPCS",,,"facility","inpatient",,,,"825","825",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG P-32 SODIUM PHOSPHATE THERAPEUTIC PER","68002300","CDM","344","RC","A9563","HCPCS",,,"facility","outpatient",,,,"825","825",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99 FANOLESOMAB DIAGNOSTIC UP TO 25","68002400","CDM","343","RC","A9566","HCPCS",,,"facility","inpatient",,,,"747","747",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TC-99 FANOLESOMAB DIAGNOSTIC UP TO 25","68002400","CDM","343","RC","A9566","HCPCS",,,"facility","outpatient",,,,"747","747",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SR-89 THERAPEUTIC PER MCI","68002500","CDM","344","RC","A9600","HCPCS",,,"facility","inpatient",,,,"4294","4294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SR-89 THERAPEUTIC PER MCI","68002500","CDM","344","RC","A9600","HCPCS",,,"facility","outpatient",,,,"4294","4294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG  RP SODIUM FLUORIDE F-18 =< 30 MCI","68002552","CDM","343","RC","A9580","HCPCS",,,"facility","inpatient",,,,"1538","1538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG  RP SODIUM FLUORIDE F-18 =< 30 MCI","68002552","CDM","343","RC","A9580","HCPCS",,,"facility","outpatient",,,,"1538","1538",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP TC99M ACUTECT DX 20MCI","68002554","CDM","343","RC","A9504","HCPCS",,,"facility","inpatient",,,,"1534","1534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP TC99M ACUTECT DX 20MCI","68002554","CDM","343","RC","A9504","HCPCS",,,"facility","outpatient",,,,"1534","1534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP I123 SOD IOD DX 1 MCI","68002555","CDM","343","RC","A9509","HCPCS",,,"facility","inpatient",,,,"953","953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP I123 SOD IOD DX 1 MCI","68002555","CDM","343","RC","A9509","HCPCS",,,"facility","outpatient",,,,"953","953",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IOFLUPANE I 123 2.5ML IJ","68002569","CDM","343","RC","A4641","HCPCS",,,"facility","inpatient",,,,"567","567",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IOFLUPANE I 123 2.5ML IJ","68002569","CDM","343","RC","A4641","HCPCS",,,"facility","outpatient",,,,"567","567",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP DXI123 IOFLUPN TO 5MCI","68002574","CDM","343","RC","A9584","HCPCS",,,"facility","inpatient",,,,"8118","8118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RP DXI123 IOFLUPN TO 5MCI","68002574","CDM","343","RC","A9584","HCPCS",,,"facility","outpatient",,,,"8118","8118",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC DIAGNOSTIC EVALUATION","72000021","CDM","900","RC","90791","HCPCS",,,"facility","inpatient",,,,"597","597",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC DIAGNOSTIC EVALUATION","72000021","CDM","900","RC","90791","HCPCS",,,"facility","outpatient",,,,"597","597",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT 30MIN","72000047","CDM","914","RC","90832","HCPCS",,,"facility","inpatient",,,,"438","438",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT 30MIN","72000047","CDM","914","RC","90832","HCPCS",,,"facility","outpatient",,,,"438","438",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT W/E&M 30MIN","72000048","CDM","914","RC","90833","HCPCS",,,"facility","inpatient",,,,"410","410",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT W/E&M 30MIN","72000048","CDM","914","RC","90833","HCPCS",,,"facility","outpatient",,,,"410","410",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT 45 MIN","72000049","CDM","914","RC","90834","HCPCS",,,"facility","inpatient",,,,"592","592",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT 45 MIN","72000049","CDM","914","RC","90834","HCPCS",,,"facility","outpatient",,,,"592","592",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT W/E&M 45MIN","72000050","CDM","914","RC","90836","HCPCS",,,"facility","inpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT W/E&M 45MIN","72000050","CDM","914","RC","90836","HCPCS",,,"facility","outpatient",,,,"451","451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT 60MIN","72000051","CDM","914","RC","90837","HCPCS",,,"facility","inpatient",,,,"675","675",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT 60MIN","72000051","CDM","914","RC","90837","HCPCS",,,"facility","outpatient",,,,"675","675",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT W/E&M 60MIN","72000052","CDM","914","RC","90838","HCPCS",,,"facility","inpatient",,,,"472","472",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCHOTHERAPY PT W/E&M 60MIN","72000052","CDM","914","RC","90838","HCPCS",,,"facility","outpatient",,,,"472","472",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PHARMACOLOGIC MGMT W/PSYTX","72000062","CDM","900","RC","90863","HCPCS",,,"facility","inpatient",,,"GY","439","439",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG PHARMACOLOGIC MGMT W/PSYTX","72000062","CDM","900","RC","90863","HCPCS",,,"facility","outpatient",,,"GY","439","439",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG PSYC TX GROUP","72000063","CDM","915","RC","90853","HCPCS",,,"facility","inpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC TX GROUP","72000063","CDM","915","RC","90853","HCPCS",,,"facility","outpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOFEEDBACK TRAINING ANY MODALITY","72000083","CDM","917","RC","90901","HCPCS",,,"facility","inpatient",,,,"163","163",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOFEEDBACK TRAINING ANY MODALITY","72000083","CDM","917","RC","90901","HCPCS",,,"facility","outpatient",,,,"163","163",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCH ELECTROCONVULSIVE THERAPY","72000099","CDM","901","RC","90870","HCPCS",,,"facility","inpatient",,,,"2550","2550",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCH ELECTROCONVULSIVE THERAPY","72000099","CDM","901","RC","90870","HCPCS",,,"facility","outpatient",,,,"2550","2550",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 45 MIN","72000100","CDM","900","RC","90876","HCPCS",,,"facility","inpatient",,,"GY","1309","1309",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 45 MIN","72000100","CDM","900","RC","90876","HCPCS",,,"facility","outpatient",,,"GY","1309","1309",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG PSYCH EVALUATION RECORDS/REPORTS/TESTS","72000102","CDM","900","RC","90885","HCPCS",,,"facility","inpatient",,,,"738","738",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYCH EVALUATION RECORDS/REPORTS/TESTS","72000102","CDM","900","RC","90885","HCPCS",,,"facility","outpatient",,,,"738","738",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NUTRITION COUNSLNG DIETN","72000173","CDM",,,,,,,"facility","inpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NUTRITION COUNSLNG DIETN","72000173","CDM",,,,,,,"facility","outpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAMILY TX W PT 50 MIN","72000202","CDM","916","RC","90847","HCPCS",,,"facility","inpatient",,,,"708","708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAMILY TX W PT 50 MIN","72000202","CDM","916","RC","90847","HCPCS",,,"facility","outpatient",,,,"708","708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAMILY TX WO PT 50 MIN","72000203","CDM","916","RC","90846","HCPCS",,,"facility","inpatient",,,,"542","542",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FAMILY TX WO PT 50 MIN","72000203","CDM","916","RC","90846","HCPCS",,,"facility","outpatient",,,,"542","542",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DEVEL TST PHYS/QHP 1ST HR","72000207","CDM","918","RC","96112","HCPCS",,,"facility","inpatient",,,,"874","874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DEVEL TST PHYS/QHP 1ST HR","72000207","CDM","918","RC","96112","HCPCS",,,"facility","outpatient",,,,"874","874",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DEVEL TST PHYS/QHP EA ADDL 30 MIN","72000208","CDM","918","RC","96113","HCPCS",,,"facility","inpatient",,,,"470","470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DEVEL TST PHYS/QHP EA ADDL 30 MIN","72000208","CDM","918","RC","96113","HCPCS",,,"facility","outpatient",,,,"470","470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC NEUROBEHAVR EXAM 1ST HR","72000209","CDM","918","RC","96116","HCPCS",,,"facility","inpatient",,,,"1083","1083",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC NEUROBEHAVR EXAM 1ST HR","72000209","CDM","918","RC","96116","HCPCS",,,"facility","outpatient",,,,"1083","1083",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROBH EXAM PHYS/QHP EA ADD HR","72000210","CDM","918","RC","96121","HCPCS",,,"facility","inpatient",,,,"1197","1197",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROBH EXAM PHYS/QHP EA ADD HR","72000210","CDM","918","RC","96121","HCPCS",,,"facility","outpatient",,,,"1197","1197",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC TEST EVAL PHYS/QHP 1ST HR","72000211","CDM","918","RC","96130","HCPCS",,,"facility","inpatient",,,,"650","650",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC TEST EVAL PHYS/QHP 1ST HR","72000211","CDM","918","RC","96130","HCPCS",,,"facility","outpatient",,,,"650","650",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC TEST EVAL PHYS/QHP EA ADD HR","72000212","CDM","918","RC","96131","HCPCS",,,"facility","inpatient",,,,"649","649",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC TEST EVAL PHYS/QHP EA ADD HR","72000212","CDM","918","RC","96131","HCPCS",,,"facility","outpatient",,,,"649","649",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROPSYC TEST EVAL PHYS/QHP 1ST HR","72000213","CDM","918","RC","96132","HCPCS",,,"facility","inpatient",,,,"1015","1015",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROPSYC TEST EVAL PHYS/QHP 1ST HR","72000213","CDM","918","RC","96132","HCPCS",,,"facility","outpatient",,,,"1015","1015",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROPSYC TEST EVAL PHYS/QHP EA ADD HR","72000214","CDM","918","RC","96133","HCPCS",,,"facility","inpatient",,,,"1151","1151",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NEUROPSYC TEST EVAL PHYS/QHP EA ADD HR","72000214","CDM","918","RC","96133","HCPCS",,,"facility","outpatient",,,,"1151","1151",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC/NEURO >=2 TEST PHYS/QHP 1ST 30 MIN","72000215","CDM","918","RC","96136","HCPCS",,,"facility","inpatient",,,,"595","595",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC/NEURO >=2 TEST PHYS/QHP 1ST 30 MIN","72000215","CDM","918","RC","96136","HCPCS",,,"facility","outpatient",,,,"595","595",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC/NEURO >=2 TEST PHYS/QHP EA ADD 30 MIN","72000216","CDM","918","RC","96137","HCPCS",,,"facility","inpatient",,,,"499","499",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC/NEURO >=2 TEST PHYS/QHP EA ADD 30 MIN","72000216","CDM","918","RC","96137","HCPCS",,,"facility","outpatient",,,,"499","499",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC/NEURO >=2 TEST BY TECH 1ST 30 MIN","72000217","CDM","918","RC","96138","HCPCS",,,"facility","inpatient",,,,"606","606",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC/NEURO >=2 TEST BY TECH 1ST 30 MIN","72000217","CDM","918","RC","96138","HCPCS",,,"facility","outpatient",,,,"606","606",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC/NEURO >=2 TEST BY TECH EA ADD 30 MIN","72000218","CDM","918","RC","96139","HCPCS",,,"facility","inpatient",,,,"606","606",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PSYC/NEURO >=2 TEST BY TECH EA ADD 30 MIN","72000218","CDM","918","RC","96139","HCPCS",,,"facility","outpatient",,,,"606","606",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COGNTIVE FNCTN INTRVEN 1ST 15 MIN","72000230","CDM","900","RC","97129","HCPCS",,,"facility","inpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COGNTIVE FNCTN INTRVEN 1ST 15 MIN","72000230","CDM","900","RC","97129","HCPCS",,,"facility","outpatient",,,,"224","224",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","72000231","CDM","900","RC","97130","HCPCS",,,"facility","inpatient",,,,"178","178",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COGNTIVE FNCTN INTRVEN EA ADDL 15 MIN","72000231","CDM","900","RC","97130","HCPCS",,,"facility","outpatient",,,,"178","178",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH PSYCHOTHERAPY PT 30MIN","72000234","CDM","914","RC","90832","HCPCS",,,"facility","inpatient",,,"95","438","438",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT 30MIN","72000234","CDM","914","RC","90832","HCPCS",,,"facility","outpatient",,,"95","438","438",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT 45 MIN","72000235","CDM","914","RC","90834","HCPCS",,,"facility","inpatient",,,"95","592","592",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT 45 MIN","72000235","CDM","914","RC","90834","HCPCS",,,"facility","outpatient",,,"95","592","592",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT 60MIN","72000236","CDM","914","RC","90837","HCPCS",,,"facility","inpatient",,,"95","675","675",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT 60MIN","72000236","CDM","914","RC","90837","HCPCS",,,"facility","outpatient",,,"95","675","675",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH FAMILY TX W PT 50 MIN","72000238","CDM","916","RC","90847","HCPCS",,,"facility","inpatient",,,"95","708","708",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH FAMILY TX W PT 50 MIN","72000238","CDM","916","RC","90847","HCPCS",,,"facility","outpatient",,,"95","708","708",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH FAMILY TX WO PT 50 MIN","72000239","CDM","916","RC","90846","HCPCS",,,"facility","inpatient",,,"95","542","542",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH FAMILY TX WO PT 50 MIN","72000239","CDM","916","RC","90846","HCPCS",,,"facility","outpatient",,,"95","542","542",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH DEVEL TST PHYS/QHP 1ST HR","72000244","CDM","918","RC","96112","HCPCS",,,"facility","inpatient",,,"95","874","874",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH DEVEL TST PHYS/QHP 1ST HR","72000244","CDM","918","RC","96112","HCPCS",,,"facility","outpatient",,,"95","874","874",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH DEVEL TST PHYS/QHP EA ADDL 30 MIN","72000245","CDM","918","RC","96113","HCPCS",,,"facility","inpatient",,,"95","470","470",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH DEVEL TST PHYS/QHP EA ADDL 30 MIN","72000245","CDM","918","RC","96113","HCPCS",,,"facility","outpatient",,,"95","470","470",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC DIAGNOSTIC EVALUATION","72000246","CDM","900","RC","90791","HCPCS",,,"facility","inpatient",,,"95","597","597",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC DIAGNOSTIC EVALUATION","72000246","CDM","900","RC","90791","HCPCS",,,"facility","outpatient",,,"95","597","597",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC NEUROBEHAVR EXAM 1ST HR","72000252","CDM","918","RC","96116","HCPCS",,,"facility","inpatient",,,"95","1083","1083",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC NEUROBEHAVR EXAM 1ST HR","72000252","CDM","918","RC","96116","HCPCS",,,"facility","outpatient",,,"95","1083","1083",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH NEUROPSYC TEST EVAL PHYS/QHP 1ST HR","72000253","CDM","918","RC","96132","HCPCS",,,"facility","inpatient",,,"95","1015","1015",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH NEUROPSYC TEST EVAL PHYS/QHP 1ST HR","72000253","CDM","918","RC","96132","HCPCS",,,"facility","outpatient",,,"95","1015","1015",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH NEUROPSYC TEST EVAL PHYS/QHP EA ADD HR","72000254","CDM","918","RC","96133","HCPCS",,,"facility","inpatient",,,"95","1151","1151",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH NEUROPSYC TEST EVAL PHYS/QHP EA ADD HR","72000254","CDM","918","RC","96133","HCPCS",,,"facility","outpatient",,,"95","1151","1151",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC/NEURO >=2 TEST PHYS/QHP 1ST 30 MIN","72000255","CDM","918","RC","96136","HCPCS",,,"facility","inpatient",,,"95","595","595",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC/NEURO >=2 TEST PHYS/QHP 1ST 30 MIN","72000255","CDM","918","RC","96136","HCPCS",,,"facility","outpatient",,,"95","595","595",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC/NEURO >=2 TEST PHYS/QHP EA ADD 30 MIN","72000256","CDM","918","RC","96137","HCPCS",,,"facility","inpatient",,,"95","499","499",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC/NEURO >=2 TEST PHYS/QHP EA ADD 30 MIN","72000256","CDM","918","RC","96137","HCPCS",,,"facility","outpatient",,,"95","499","499",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC/NEURO >=2 TEST BY TECH 1ST 30 MIN","72000257","CDM","918","RC","96138","HCPCS",,,"facility","inpatient",,,"95","606","606",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC/NEURO >=2 TEST BY TECH 1ST 30 MIN","72000257","CDM","918","RC","96138","HCPCS",,,"facility","outpatient",,,"95","606","606",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC/NEURO >=2 TEST BY TECH EA ADD 30 MIN","72000258","CDM","918","RC","96139","HCPCS",,,"facility","inpatient",,,"95","606","606",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC/NEURO >=2 TEST BY TECH EA ADD 30 MIN","72000258","CDM","918","RC","96139","HCPCS",,,"facility","outpatient",,,"95","606","606",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH NEUROBH EXAM PHYS/QHP EA ADD HR","72000259","CDM","918","RC","96121","HCPCS",,,"facility","inpatient",,,"95","1197","1197",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH NEUROBH EXAM PHYS/QHP EA ADD HR","72000259","CDM","918","RC","96121","HCPCS",,,"facility","outpatient",,,"95","1197","1197",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC TEST EVAL PHYS/QHP 1ST HR","72000262","CDM","918","RC","96130","HCPCS",,,"facility","inpatient",,,"95","650","650",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC TEST EVAL PHYS/QHP 1ST HR","72000262","CDM","918","RC","96130","HCPCS",,,"facility","outpatient",,,"95","650","650",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC TEST EVAL PHYS/QHP EA ADD HR","72000263","CDM","918","RC","96131","HCPCS",,,"facility","inpatient",,,"95","649","649",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYC TEST EVAL PHYS/QHP EA ADD HR","72000263","CDM","918","RC","96131","HCPCS",,,"facility","outpatient",,,"95","649","649",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT W/E&M 30MIN","72000264","CDM","914","RC","90833","HCPCS",,,"facility","inpatient",,,"95","410","410",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT W/E&M 30MIN","72000264","CDM","914","RC","90833","HCPCS",,,"facility","outpatient",,,"95","410","410",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT W/E&M 45MIN","72000265","CDM","914","RC","90836","HCPCS",,,"facility","inpatient",,,"95","451","451",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT W/E&M 45MIN","72000265","CDM","914","RC","90836","HCPCS",,,"facility","outpatient",,,"95","451","451",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT W/E&M 60MIN","72000266","CDM","914","RC","90838","HCPCS",,,"facility","inpatient",,,"95","472","472",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH PSYCHOTHERAPY PT W/E&M 60MIN","72000266","CDM","914","RC","90838","HCPCS",,,"facility","outpatient",,,"95","472","472",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG MLT FAM GROUP BHV MGMT/MODIFICAJ TRAING 1ST 60","72000267","CDM","916","RC","96202","HCPCS",,,"facility","inpatient",,,,"784","784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MLT FAM GROUP BHV MGMT/MODIFICAJ TRAING 1ST 60","72000267","CDM","916","RC","96202","HCPCS",,,"facility","outpatient",,,,"784","784",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MLT FAM GROUP BHV MGMT/MODIFICAJ TRAING EA ADDL","72000268","CDM","916","RC","96203","HCPCS",,,"facility","inpatient",,,,"197","197",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MLT FAM GROUP BHV MGMT/MODIFICAJ TRAING EA ADDL","72000268","CDM","916","RC","96203","HCPCS",,,"facility","outpatient",,,,"197","197",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LABOR LEVEL 1 NORMAL PER HOUR INPATIENT","75000000","CDM","721","RC",,,,,"facility","inpatient",,,,"907","907",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LABOR LEVEL 1 NORMAL PER HOUR INPATIENT","75000000","CDM","721","RC",,,,,"facility","outpatient",,,,"907","907",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LABOR LEVEL 2 HIGH RISK PER HOUR INPATIENT","75000001","CDM","721","RC",,,,,"facility","inpatient",,,,"1162","1162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LABOR LEVEL 2 HIGH RISK PER HOUR INPATIENT","75000001","CDM","721","RC",,,,,"facility","outpatient",,,,"1162","1162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DELIVERY VAGINAL LEVEL 1 NORMAL","75000002","CDM","722","RC",,,,,"facility","inpatient",,,,"6314","6314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DELIVERY VAGINAL LEVEL 1 NORMAL","75000002","CDM","722","RC",,,,,"facility","outpatient",,,,"6314","6314",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DELIVERY VAGINAL LEVEL 2 HIGH RISK","75000003","CDM","722","RC",,,,,"facility","inpatient",,,,"6581","6581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DELIVERY VAGINAL LEVEL 2 HIGH RISK","75000003","CDM","722","RC",,,,,"facility","outpatient",,,,"6581","6581",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCT (OXYTOCIN CHLNG TEST)","75000006","CDM","920","RC","59020","HCPCS",,,"facility","inpatient",,,,"1580","1580",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCT (OXYTOCIN CHLNG TEST)","75000006","CDM","920","RC","59020","HCPCS",,,"facility","outpatient",,,,"1580","1580",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NST (FETAL NON-STRESS TEST)","75000009","CDM","920","RC","59025","HCPCS",,,"facility","inpatient",,,,"993","993",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NST (FETAL NON-STRESS TEST)","75000009","CDM","920","RC","59025","HCPCS",,,"facility","outpatient",,,,"993","993",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ABR SCREEN INIT IP","75000014","CDM","470","RC","92586","HCPCS",,,"facility","outpatient",,,,"662","662",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NON HOSPITAL DELIVERY/POST DELIVERY CARE","75000030","CDM","722","RC",,,,,"facility","inpatient",,,,"4130","4130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG NON HOSPITAL DELIVERY/POST DELIVERY CARE","75000030","CDM","722","RC",,,,,"facility","outpatient",,,,"4130","4130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 ADDL 15 MIN L&D","75000037","CDM","360","RC",,,,,"facility","inpatient",,,,"1300","1300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 ADDL 15 MIN L&D","75000037","CDM","360","RC",,,,,"facility","outpatient",,,,"1300","1300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 FIRST 30 MIN L&D","75000038","CDM","360","RC",,,,,"facility","inpatient",,,,"3940","3940",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 1 FIRST 30 MIN L&D","75000038","CDM","360","RC",,,,,"facility","outpatient",,,,"3940","3940",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 ADDL 15 MIN L&D","75000039","CDM","360","RC",,,,,"facility","inpatient",,,,"1690","1690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 ADDL 15 MIN L&D","75000039","CDM","360","RC",,,,,"facility","outpatient",,,,"1690","1690",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 FIRST 30 MIN L&D","75000040","CDM","360","RC",,,,,"facility","inpatient",,,,"5122","5122",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 2 FIRST 30 MIN L&D","75000040","CDM","360","RC",,,,,"facility","outpatient",,,,"5122","5122",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 ADDL 15 MIN L&D","75000041","CDM","360","RC",,,,,"facility","inpatient",,,,"2080","2080",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 ADDL 15 MIN L&D","75000041","CDM","360","RC",,,,,"facility","outpatient",,,,"2080","2080",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 FIRST 30M L & D","75000042","CDM","360","RC",,,,,"facility","inpatient",,,,"6304","6304",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 3 FIRST 30M L & D","75000042","CDM","360","RC",,,,,"facility","outpatient",,,,"6304","6304",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 ADD 15M L & D","75000043","CDM","360","RC",,,,,"facility","inpatient",,,,"2991","2991",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 ADD 15M L & D","75000043","CDM","360","RC",,,,,"facility","outpatient",,,,"2991","2991",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 FIRST 30M L & D","75000044","CDM","360","RC",,,,,"facility","inpatient",,,,"9062","9062",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SURG LVL 4 FIRST 30M L & D","75000044","CDM","360","RC",,,,,"facility","outpatient",,,,"9062","9062",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLASTIC REP UTERINE CERVIX VAGINAL","75000083","CDM","361","RC","57720","HCPCS",,,"facility","inpatient",,,,"15061","15061",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PLASTIC REP UTERINE CERVIX VAGINAL","75000083","CDM","361","RC","57720","HCPCS",,,"facility","outpatient",,,,"15061","15061",,,,,,,,,,,,,"Gross Charge Type: Standard"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0250","RC","J2359","HCPCS","31722-308-01","NDC","facility","inpatient","0.059090","UN","JZ","13.82","13.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0250","RC","J2359","HCPCS","0781-3159-72","NDC","facility","inpatient","0.050000","UN","JZ","14.33","14.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0250","RC","J2359","HCPCS","0002-7597-01","NDC","facility","inpatient","0.094444","UN","JZ","19.60","19.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN","80000001","CDM","0250","RC","J3490","HCPCS","70069-363-01","NDC","facility","inpatient","4.120689","ML",,"43.84","43.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOLIC ACID 5 MG/ML IJ SOLN","80000001","CDM","0250","RC","J3490","HCPCS","63323-184-10","NDC","facility","inpatient","0.309090","ML",,"71.77","71.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 7% IN NEBU","80000001","CDM","0250","RC","J3490","HCPCS","50190-740-60","NDC","facility","inpatient","1.000000","ML",,"0.60","0.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0250","RC","J3490","HCPCS","45802-759-00","NDC","facility","inpatient","0.772727","UN",,"60.78","60.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 12.5 MG PR SUPP","80000001","CDM","0250","RC","J3490","HCPCS","45802-758-30","NDC","facility","inpatient","1.000000","UN",,"70.82","70.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 12.5 MG PR SUPP","80000001","CDM","0250","RC","J3490","HCPCS","45802-758-00","NDC","facility","inpatient","0.875000","UN",,"59.77","59.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","J3490","HCPCS","20555-00400","NDC","facility","inpatient","1.406250","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","J3490","HCPCS","17856-496-03","NDC","facility","inpatient","4.991749","ML",,"17.29","17.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","J3490","HCPCS","0904-5492-80","NDC","facility","inpatient","3.700000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","J3490","HCPCS","0904-5492-61","NDC","facility","inpatient","4.666666","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0250","RC","J3490","HCPCS","0904-0539-61","NDC","facility","inpatient","1.971830","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0250","RC","J3490","HCPCS","0713-0526-12","NDC","facility","inpatient","0.625000","UN",,"59.76","59.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN","80000001","CDM","0250","RC","J3490","HCPCS","0703-9526-01","NDC","facility","inpatient","4.906666","ML",,"48","48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN","80000001","CDM","0250","RC","J3490","HCPCS","0703-9514-03","NDC","facility","inpatient","5.000000","ML",,"52.68","52.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","J3490","HCPCS","65862-496-47","NDC","facility","inpatient","5.000000","ML",,"12.51","12.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0250","RC","J3490","HCPCS","0591-2992-39","NDC","facility","inpatient","0.750000","UN",,"59.76","59.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUFENTANIL CITRATE 100 MCG/2ML IV SOLN","80000001","CDM","0250","RC","J3490","HCPCS","0409-3382-22","NDC","facility","inpatient","0.675000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR INJECTION IJ SOLN","80000001","CDM","0250","RC","J3490","HCPCS","0338-0013-04","NDC","facility","inpatient","23.809500","ML",,"3.39","3.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","J3490","HCPCS","0121-0853-20","NDC","facility","inpatient","5.000000","ML",,"20.42","20.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0250","RC","J3490","HCPCS","0781-3159-72","NDC","facility","inpatient","1.000000","UN","JZ","269.75","269.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0250","RC","J3490","HCPCS","0517-0955-01","NDC","facility","inpatient","0.500000","UN","JZ","165.87","165.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0250","RC","J3490","HCPCS","0002-7597-01","NDC","facility","inpatient","0.500000","UN","JZ","210","210",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMINOCAPROIC ACID 250 MG/ML IV SOLN","80000001","CDM","0250","RC","J3490","HCPCS","0517-9120-01","NDC","facility","inpatient","19.862068","ML",,"78.90","78.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM TETRADECYL SULFATE 3 % IV SOLN","80000001","CDM","0250","RC","J3490","HCPCS","67457-163-02","NDC","facility","inpatient","1.000000","ML",,"187.50","187.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0250","RC","J3490","HCPCS","0904-0530-61","NDC","facility","inpatient","5.666666","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"B-COMPLEX+VITAMIN C PO TABS SH","80000001","CDM","0250","RC","J3490","HCPCS","80681-12600","NDC","facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN","80000001","CDM","0250","RC","J3490","HCPCS","67457-779-30","NDC","facility","inpatient","4.916090","ML",,"46.25","46.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 7% IN NEBU","80000001","CDM","0250","RC","J3490","HCPCS","83490-207-60","NDC","facility","inpatient","1.109324","ML",,"0.60","0.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMINOCAPROIC ACID 250 MG/ML IV SOLN","80000001","CDM","0250","RC","S0017","HCPCS","0517-9120-01","NDC","facility","inpatient","20.000000","ML",,"75.6","75.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMINOCAPROIC ACID 250 MG/ML IV SOLN","80000001","CDM","0250","RC","S0017","HCPCS","0409-4346-73","NDC","facility","inpatient","20.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","S0028","HCPCS","67457-433-22","NDC","facility","inpatient","2.258976","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","S0028","HCPCS","63323-739-12","NDC","facility","inpatient","2.241006","ML","JZ","74.44","74.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","S0028","HCPCS","0641-6022-25","NDC","facility","inpatient","2.425487","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN","80000001","CDM","0250","RC","S0039","HCPCS","67457-779-30","NDC","facility","inpatient","10.000000","ML",,"105.04","105.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENTAMIDINE ISETHIONATE 300 MG IJ SOLR","80000001","CDM","0250","RC","S0080","HCPCS","13925-515-10","NDC","facility","inpatient","0.307525","UN",,"361.76","361.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 100 MCG PO TABS","80000001","CDM","0250","RC","S0191","HCPCS","70954-443-10","NDC","facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 200 MCG PO TABS","80000001","CDM","0250","RC","S0191","HCPCS","60687-746-11","NDC","facility","inpatient","1.244635","UN",,"12.19","12.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 100 MCG PO TABS","80000001","CDM","0250","RC","S0191","HCPCS","59762-5007-2","NDC","facility","inpatient","0.976190","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 100 MCG PO TABS","80000001","CDM","0250","RC","S0191","HCPCS","59762-5007-1","NDC","facility","inpatient","0.585313","UN",,"14.99","14.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 200 MCG PO TABS","80000001","CDM","0250","RC","S0191","HCPCS","0025-1461-31","NDC","facility","inpatient","1.248275","UN",,"22.24","22.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","Z7610","HCPCS","0904-5492-80","NDC","facility","inpatient","1.987421","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"B-COMPLEX+VITAMIN C PO TABS SH","80000001","CDM","0250","RC","Z7610","HCPCS","80681-12600","NDC","facility","inpatient","1.133333","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","Z7610","HCPCS","50383-824-21","NDC","facility","inpatient","5.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0250","RC","Z7610","HCPCS","45802-759-00","NDC","facility","inpatient","0.625000","UN",,"54.24","54.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 12.5 MG PR SUPP","80000001","CDM","0250","RC","Z7610","HCPCS","45802-758-30","NDC","facility","inpatient","1.000000","UN",,"70.82","70.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","Z7610","HCPCS","20555-00400","NDC","facility","inpatient","1.677595","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","Z7610","HCPCS","17856-823-02","NDC","facility","inpatient","4.963358","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","Z7610","HCPCS","17856-496-03","NDC","facility","inpatient","4.743119","ML",,"20.00","20.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0250","RC","Z7610","HCPCS","0904-0539-61","NDC","facility","inpatient","1.867256","UN",,"2.02","2.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0250","RC","Z7610","HCPCS","0904-0530-61","NDC","facility","inpatient","5.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0250","RC","Z7610","HCPCS","0713-0526-12","NDC","facility","inpatient","0.800000","UN",,"61.97","61.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0250","RC","Z7610","HCPCS","0591-2992-39","NDC","facility","inpatient","1.000000","UN",,"70.82","70.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","Z7610","HCPCS","0121-0853-20","NDC","facility","inpatient","4.861111","ML",,"28.64","28.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","Z7610","HCPCS","0904-5492-61","NDC","facility","inpatient","3.775510","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 200 MCG PO TABS","80000001","CDM","0250","RC","0025-1461-31","NDC",,,"facility","inpatient","1.000000","UN",,"23.44","23.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","0121-0853-20","NDC",,,"facility","inpatient","76.421052","ML",,"70.49","70.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG/100ML IV SOLN","80000001","CDM","0250","RC","0409-0152-24","NDC",,,"facility","inpatient","900.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","80000001","CDM","0250","RC","0409-1165-01","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUFENTANIL CITRATE 100 MCG/2ML IV SOLN","80000001","CDM","0250","RC","0409-3382-22","NDC",,,"facility","inpatient","2.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMINOCAPROIC ACID 250 MG/ML IV SOLN","80000001","CDM","0250","RC","0409-4346-73","NDC",,,"facility","inpatient","40.000000","ML",,"56.81","56.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN","80000001","CDM","0250","RC","0409-7811-24","NDC",,,"facility","inpatient","300.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMINOCAPROIC ACID 250 MG/ML IV SOLN","80000001","CDM","0250","RC","0517-9120-01","NDC",,,"facility","inpatient","20.615384","ML",,"79.1","79.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","0536-4661-10","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE 25 MG PR SUPP","80000001","CDM","0250","RC","0574-7226-12","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","0641-6022-25","NDC",,,"facility","inpatient","2.000000","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","0641-6022-25","NDC",,,"facility","inpatient","2.674408","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0250","RC","0904-0530-61","NDC",,,"facility","inpatient","2.428571","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0250","RC","0904-0539-61","NDC",,,"facility","inpatient","1.780441","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","0904-5492-61","NDC",,,"facility","inpatient","1.783505","UN",,"1.96","1.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","0904-5492-80","NDC",,,"facility","inpatient","1.802507","UN",,"1.96","1.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0250","RC","17856-496-03","NDC",,,"facility","inpatient","32.413793","ML",,"47.76","47.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","20555-00400","NDC",,,"facility","inpatient","2.158227","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0250","RC","45802-759-00","NDC",,,"facility","inpatient","3.000000","UN",,"70.84","70.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 7% IN NEBU","80000001","CDM","0250","RC","50190-740-60","NDC",,,"facility","inpatient","4.000000","ML",,"1.67","1.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 100 MCG PO TABS","80000001","CDM","0250","RC","59762-5007-1","NDC",,,"facility","inpatient","0.977064","UN",,"14.53","14.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 200 MCG PO TABS","80000001","CDM","0250","RC","60687-746-11","NDC",,,"facility","inpatient","5.457142","UN",,"11.43","11.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOLIC ACID 5 MG/ML IJ SOLN","80000001","CDM","0250","RC","63323-184-10","NDC",,,"facility","inpatient","21.590909","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","63323-739-12","NDC",,,"facility","inpatient","2.285714","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","63323-739-12","NDC",,,"facility","inpatient","3.213764","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM TETRADECYL SULFATE 3 % IV SOLN","80000001","CDM","0250","RC","67457-163-02","NDC",,,"facility","inpatient","2.000000","ML",,"503.92","503.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","67457-433-22","NDC",,,"facility","inpatient","3.600000","ML",,"73.17","73.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0250","RC","67457-433-22","NDC",,,"facility","inpatient","2.341463","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0250","RC","68176-00015","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"B-COMPLEX+VITAMIN C PO TABS SH","80000001","CDM","0250","RC","80681-12600","NDC",,,"facility","inpatient","1.173913","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 7% IN NEBU","80000001","CDM","0250","RC","83490-207-60","NDC",,,"facility","inpatient","6.109890","ML",,"1.64","1.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0636","RC","J2359","HCPCS","31722-308-01","NDC","facility","outpatient","0.068181","UN","JZ","13.22","13.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0636","RC","J2359","HCPCS","0781-3159-72","NDC","facility","outpatient","0.056060","UN","JZ","11.19","11.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0636","RC","J2359","HCPCS","0002-7597-01","NDC","facility","outpatient","0.104545","UN","JZ","12.82","12.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0636","RC","J3490","HCPCS","0781-3159-72","NDC","facility","outpatient","5.250000","UN","JZ","5.81","5.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","80000001","CDM","0636","RC","J3490","HCPCS","0002-7597-01","NDC","facility","outpatient","0.250000","UN","JZ","98.00","98.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0636","RC","J3490","HCPCS","0121-0853-20","NDC","facility","outpatient","14.650000","ML",,"16.25","16.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR INJECTION IJ SOLN","80000001","CDM","0636","RC","J3490","HCPCS","0409-4887-10","NDC","facility","outpatient","4.439130","ML",,"6.01","6.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0636","RC","J3490","HCPCS","0713-0526-12","NDC","facility","outpatient","1.000000","UN",,"70.82","70.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0636","RC","J3490","HCPCS","0904-0539-61","NDC","facility","outpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0636","RC","J3490","HCPCS","0904-5492-80","NDC","facility","outpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PR SUPP","80000001","CDM","0636","RC","J3490","HCPCS","45802-759-00","NDC","facility","outpatient","1.000000","UN",,"70.84","70.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOLIC ACID 5 MG/ML IJ SOLN","80000001","CDM","0636","RC","J3490","HCPCS","63323-184-10","NDC","facility","outpatient","0.238095","ML",,"68.20","68.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM TETRADECYL SULFATE 3 % IV SOLN","80000001","CDM","0636","RC","J3490","HCPCS","67457-163-02","NDC","facility","outpatient","1.000000","ML",,"223.22","223.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN","80000001","CDM","0636","RC","J3490","HCPCS","67457-779-30","NDC","facility","outpatient","3.460000","ML",,"38.74","38.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0636","RC","J3490","HCPCS","17856-496-03","NDC","facility","outpatient","2.750000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","S0028","HCPCS","67457-433-22","NDC","facility","outpatient","2.063492","ML","PN,JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","S0028","HCPCS","63323-739-12","NDC","facility","outpatient","2.375000","ML","PN,JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","S0028","HCPCS","67457-433-22","NDC","facility","outpatient","2.888888","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","S0028","HCPCS","63323-739-12","NDC","facility","outpatient","8.071764","ML","JZ","126.56","126.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","S0028","HCPCS","0641-6022-25","NDC","facility","outpatient","2.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENTAMIDINE ISETHIONATE 300 MG/3ML IJ (WET SOLR VIAL)","80000001","CDM","0636","RC","S0080","HCPCS","23155-748-31","NDC","facility","outpatient","0.793333","UN",,"579.02","579.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENTAMIDINE ISETHIONATE 300 MG IJ SOLR","80000001","CDM","0636","RC","S0080","HCPCS","13925-515-10","NDC","facility","outpatient","0.871100","UN",,"852.56","852.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 200 MCG PO TABS","80000001","CDM","0636","RC","S0191","HCPCS","60687-746-11","NDC","facility","outpatient","1.000000","UN",,"15.00","15.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 100 MCG PO TABS","80000001","CDM","0636","RC","S0191","HCPCS","59762-5007-1","NDC","facility","outpatient","1","EA",,"9.06","9.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 7.142857 TAB"
"MISOPROSTOL 200 MCG PO TABS","80000001","CDM","0636","RC","S0191","HCPCS","0025-1461-31","NDC","facility","outpatient","1.000000","UN",,"20.95","20.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0636","RC","Z7610","HCPCS","20555-00400","NDC","facility","outpatient","1.000000","UN",,"4.02","4.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0636","RC","Z7610","HCPCS","17856-496-03","NDC","facility","outpatient","4.678571","ML",,"16.07","16.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0636","RC","Z7610","HCPCS","0904-5492-80","NDC","facility","outpatient","1.500000","UN",,"5.03","5.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0636","RC","Z7610","HCPCS","0904-5492-61","NDC","facility","outpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0636","RC","Z7610","HCPCS","0904-0539-61","NDC","facility","outpatient","1.347826","UN",,"3.05","3.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP","80000001","CDM","0636","RC","Z7610","HCPCS","0121-0853-20","NDC","facility","outpatient","4.666666","ML",,"21.67","21.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","80000001","CDM","0636","RC","0409-1165-01","NDC",,,"facility","outpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","80000001","CDM","0636","RC","0904-0539-61","NDC",,,"facility","outpatient","5.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","80000001","CDM","0636","RC","0904-5492-80","NDC",,,"facility","outpatient","3.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MISOPROSTOL 200 MCG PO TABS","80000001","CDM","0636","RC","60687-746-11","NDC",,,"facility","outpatient","1.000000","UN",,"15.00","15.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOLIC ACID 5 MG/ML IJ SOLN","80000001","CDM","0636","RC","63323-184-10","NDC",,,"facility","outpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","63323-739-12","NDC",,,"facility","outpatient","22.317460","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","63323-739-12","NDC",,,"facility","outpatient","2.000000","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","67457-433-22","NDC",,,"facility","outpatient","2.000000","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","80000001","CDM","0636","RC","67457-433-22","NDC",,,"facility","outpatient","2.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE 8 MG PO TABS","80000003","CDM","0250","RC","J7509","HCPCS","59762-0049-1","NDC","facility","inpatient","0.500000","UN",,"5.53","5.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE 4 MG PO TABS","80000003","CDM","0250","RC","J7509","HCPCS","68084-149-01","NDC","facility","inpatient","0.930555","UN",,"13.64","13.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE 8 MG PO TABS","80000003","CDM","0250","RC","J7509","HCPCS","68382-917-11","NDC","facility","inpatient","0.500000","UN",,"5.54","5.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0250","RC","J8501","HCPCS","0006-0464-05","NDC","facility","inpatient","0.125000","UN",,"53.12","53.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0250","RC","J8501","HCPCS","0781-2321-06","NDC","facility","inpatient","0.154850","UN",,"41.23","41.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0250","RC","J8501","HCPCS","68462-583-40","NDC","facility","inpatient","0.180555","UN",,"41.23","41.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 80 MG PO CAPS","80000003","CDM","0250","RC","J8501","HCPCS","68462-584-40","NDC","facility","inpatient","0.062500","UN",,"38.20","38.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPHOSPHAMIDE 25 MG PO CAPS","80000003","CDM","0250","RC","J8530","HCPCS","54879-021-01","NDC","facility","inpatient","1.000000","UN",,"27.25","27.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPHOSPHAMIDE 50 MG PO CAPS","80000003","CDM","0250","RC","J8530","HCPCS","54879-022-01","NDC","facility","inpatient","0.500000","UN",,"15.6","15.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPHOSPHAMIDE 25 MG PO CAPS","80000003","CDM","0250","RC","J8530","HCPCS","62332-618-31","NDC","facility","inpatient","1.000000","UN",,"58.38","58.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPHOSPHAMIDE 50 MG PO CAPS","80000003","CDM","0250","RC","J8530","HCPCS","62332-619-31","NDC","facility","inpatient","0.500000","UN",,"53.61","53.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","80000003","CDM","0250","RC","Q0164","HCPCS","50268-684-11","NDC","facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 10 MG PO TABS","80000003","CDM","0250","RC","Q0164","HCPCS","50268-685-11","NDC","facility","inpatient","0.601449","UN",,"8.35","8.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","80000003","CDM","0250","RC","Q0164","HCPCS","59746-113-06","NDC","facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DRONABINOL 5 MG PO CAPS","80000003","CDM","0250","RC","Q0167","HCPCS","67877-754-60","NDC","facility","inpatient","0.614285","UN",,"32.5","32.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DRONABINOL 5 MG PO CAPS","80000003","CDM","0250","RC","Q0167","HCPCS","60687-386-21","NDC","facility","inpatient","0.500000","UN",,"34.36","34.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DRONABINOL 2.5 MG PO CAPS","80000003","CDM","0250","RC","Q0167","HCPCS","60687-375-01","NDC","facility","inpatient","1.111888","UN",,"44.68","44.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DRONABINOL 5 MG PO CAPS","80000003","CDM","0250","RC","Q0167","HCPCS","42858-868-06","NDC","facility","inpatient","3.125000","UN",,"20","20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DRONABINOL 2.5 MG PO CAPS","80000003","CDM","0250","RC","Q0167","HCPCS","0904-7144-61","NDC","facility","inpatient","1.800000","UN",,"39.23","39.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PO TABS","80000003","CDM","0250","RC","Q0169","HCPCS","0904-6461-61","NDC","facility","inpatient","0.500000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PO TABS","80000003","CDM","0250","RC","Q0169","HCPCS","0781-1830-01","NDC","facility","inpatient","0.500000","UN",,"7.22","7.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PO TABS","80000003","CDM","0250","RC","Q0169","HCPCS","0904-7304-61","NDC","facility","inpatient","0.556133","UN",,"7.52","7.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERPHENAZINE 4 MG PO TABS","80000003","CDM","0250","RC","Q0175","HCPCS","68084-602-01","NDC","facility","inpatient","1.000000","UN",,"12.12","12.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","80000003","CDM","0250","RC","Z7610","HCPCS","50268-684-11","NDC","facility","inpatient","1.000000","UN",,"8.86","8.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 10 MG PO TABS","80000003","CDM","0250","RC","Z7610","HCPCS","50268-685-11","NDC","facility","inpatient","1.852380","UN",,"7.86","7.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE 8 MG PO TABS","80000003","CDM","0250","RC","Z7610","HCPCS","59762-0049-1","NDC","facility","inpatient","0.500000","UN",,"5.53","5.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DRONABINOL 5 MG PO CAPS","80000003","CDM","0250","RC","Z7610","HCPCS","67877-754-60","NDC","facility","inpatient","0.500000","UN",,"32.5","32.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PO TABS","80000003","CDM","0250","RC","Z7610","HCPCS","0904-7304-61","NDC","facility","inpatient","1.209090","UN",,"7.65","7.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0250","RC","Z7610","HCPCS","68462-583-40","NDC","facility","inpatient","0.250000","UN",,"27.72","27.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 80 MG PO CAPS","80000003","CDM","0250","RC","Z7610","HCPCS","68462-584-40","NDC","facility","inpatient","0.062500","UN",,"38.20","38.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 125 MG PO CAPS","80000003","CDM","0250","RC","Z7610","HCPCS","68462-585-40","NDC","facility","inpatient","0.040000","UN",,"38.21","38.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 10 MG PO TABS","80000003","CDM","0250","RC","Z7610","HCPCS","50268-685-11","NDC","facility","inpatient","0.500000","UN","PN","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DRONABINOL 2.5 MG PO CAPS","80000003","CDM","0250","RC","Z7610","HCPCS","60687-375-01","NDC","facility","inpatient","1.363636","UN",,"44.14","44.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DRONABINOL 2.5 MG PO CAPS","80000003","CDM","0250","RC","Z7610","HCPCS","0904-7144-61","NDC","facility","inpatient","1.833333","UN",,"32.5","32.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PO TABS","80000003","CDM","0250","RC","Z7610","HCPCS","0781-1830-01","NDC","facility","inpatient","0.500000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0250","RC","Z7610","HCPCS","0781-2321-06","NDC","facility","inpatient","0.171875","UN",,"33.10","33.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE 4 MG PO TABS","80000003","CDM","0636","RC","J7509","HCPCS","0603-4593-21","NDC","facility","outpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE 8 MG PO TABS","80000003","CDM","0636","RC","J7509","HCPCS","59762-0049-1","NDC","facility","outpatient","0.500000","UN",,"6.02","6.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0636","RC","J8501","HCPCS","0006-0464-05","NDC","facility","outpatient","0.125000","UN","JZ","53.12","53.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0636","RC","J8501","HCPCS","0006-0464-05","NDC","facility","outpatient","0.125000","UN",,"53.12","53.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0636","RC","J8501","HCPCS","0781-2321-06","NDC","facility","outpatient","0.130208","UN",,"41.23","41.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APREPITANT 40 MG PO CAPS","80000003","CDM","0636","RC","J8501","HCPCS","68462-583-40","NDC","facility","outpatient","0.125000","UN",,"41.23","41.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 10 MG PO TABS","80000003","CDM","0636","RC","Q0164","HCPCS","50268-685-11","NDC","facility","outpatient","0.500000","UN","PN","10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","80000003","CDM","0636","RC","Q0164","HCPCS","50268-684-11","NDC","facility","outpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 10 MG PO TABS","80000003","CDM","0636","RC","Q0164","HCPCS","50268-685-11","NDC","facility","outpatient","26.833333","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","80000003","CDM","0636","RC","Q0164","HCPCS","51079-541-20","NDC","facility","outpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 12.5 MG PO TABS","80000003","CDM","0636","RC","Q0169","HCPCS","68382-040-01","NDC","facility","outpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE HCL 25 MG PO TABS","80000003","CDM","0636","RC","Q0169","HCPCS","0904-7304-61","NDC","facility","outpatient","5.833333","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERPHENAZINE 4 MG PO TABS","80000003","CDM","0636","RC","Q0175","HCPCS","68084-602-01","NDC","facility","outpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STUDY RX: INVESTIGATIONAL MIRVETUXIMAB SORAVTANSINE (IMGN853) 100MG/20ML IV SOLN SH","80000006","CDM","0250","RC","J9999","HCPCS","99999-0026-56","NDC","facility","inpatient","64.000000","ML",,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STUDY RX: INVESTIGATIONAL MK-2870 200MG/10ML IV SOLN SH","80000006","CDM","0636","RC","J9999","HCPCS","99999-0038-45","NDC","facility","outpatient","0.626000","UN","PN","0.005","0.005",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL PACLITAXEL PROTEIN-BOUND 100MG IV SUSR","80000006","CDM","0636","RC","J9999","HCPCS","99999-0036-87","NDC","facility","outpatient","1.201666","UN","PN","0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL MIRVETUXIMAB SORAVTANSINE (IMGN853) 100MG/20ML IV SOLN SH","80000006","CDM","0636","RC","J9999","HCPCS","99999-0026-56","NDC","facility","outpatient","69.891549","ML","PN","0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL PACLITAXEL PROTEIN-BOUND 100MG IV SUSR","80000006","CDM","0636","RC","J9999","HCPCS","68817-134-50","NDC","facility","outpatient","1.200000","UN","PN","0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL MIRVETUXIMAB SORAVTANSINE (IMGN853) 100MG/20ML IV SOLN SH","80000006","CDM","0636","RC","J9999","HCPCS","99999-0026-56","NDC","facility","outpatient","64.000000","ML",,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STUDY RX: INVESTIGATIONAL BXQ-350 8.8MG IV SOLR","80000006","CDM","0636","RC","J9999","HCPCS","99999-0036-88","NDC","facility","outpatient","20.611538","UN","PN","0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL MK-3475 (PEMBROLIZUMAB) 100MG/4ML IV SOLN SH","80000006","CDM","0636","RC","99999-0025-62","NDC",,,"facility","outpatient","4.000000","ML","PN","0.0042","0.0042",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL PEMBROLIZUMAB 100MG/4ML IV SOLN SH","80000006","CDM","0636","RC","99999-0026-37","NDC",,,"facility","outpatient","1.033472","ML","PN","0.0013","0.0013",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL STRO-002 10MG/ML IV SOLN SH","80000006","CDM","0636","RC","99999-0036-10","NDC",,,"facility","outpatient","10.000000","ML","PN","0.0033","0.0033",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL MK-7684A (VIBOSTOLIMAB 200MG/PEMBROLIZUMB 200MG) OR PEMBROLIZUMAB 200MG IV SOLN SH","80000006","CDM","0636","RC","99999-0037-25","NDC",,,"facility","outpatient","1.035087","UN","PN","0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL NIVOLUMAB 100MG/10ML IV SOLN SH","80000007","CDM","0250","RC","99999-0024-97","NDC",,,"facility","inpatient","1.000000","ML","PN","0.0003","0.0003",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL SARGRAMOSTIM 250MCG IV SOLR","80000007","CDM","0250","RC","99999-0026-18","NDC",,,"facility","inpatient","1.210526","UN","PN","0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL MRNA-4157 1MG/ML IM SOLN","80000007","CDM","0250","RC","99999-0032-57","NDC",,,"facility","inpatient","1.190476","ML","PN","0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL DAPAGLIFLOZIN 10MG OR PLACEBO","80000007","CDM","0250","RC","99999-0033-16","NDC",,,"facility","inpatient","1.000000","UN",,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STUDY RX: INVESTIGATIONAL ADUCANUMAB OR PLACEBO 300MG/3ML IV SOLN SH","80000007","CDM","0250","RC","99999-0037-21","NDC",,,"facility","inpatient","4.112758","ML","PN","0.0043","0.0043",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL R2R01 10MG/ML INJ","80000007","CDM","0250","RC","99999-0037-42","NDC",,,"facility","inpatient","1.000000","UN",,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STUDY RX: INVESTIGATIONAL R2R01 10MG/ML IV SOLN SH","80000007","CDM","0250","RC","99999-0037-45","NDC",,,"facility","inpatient","1.000000","UN",,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZZ STUDY RX: INVESTIGATIONAL MILVEXIAN 25MG PO CAPS OR PLACEBO","80000007","CDM","0250","RC","99999-0037-65","NDC",,,"facility","inpatient","1.000000","UN",,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STUDY RX: INVESTIGATIONAL DONANEMAB OR PLACEBO 17.5MG/ML IV SOLN SH","80000007","CDM","0250","RC","99999-0037-78","NDC",,,"facility","inpatient","100.000000","ML","PN","0.005","0.005",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL NIVOLUMAB 100MG/10ML IV SOLN SH","80000007","CDM","0636","RC","99999-0024-97","NDC",,,"facility","outpatient","1.000000","ML","PN","0.0004","0.0004",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL IPILIMUMAB 5MG/ML IV SOLN SH","80000007","CDM","0636","RC","99999-0025-54","NDC",,,"facility","outpatient","1.000000","ML","PN","0.0001","0.0001",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL MRNA-4157 1MG/ML IM SOLN","80000007","CDM","0636","RC","99999-0032-57","NDC",,,"facility","outpatient","1.292682","ML","PN","0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL LIVMONIPLIMAB (ABBV-151) 200MG/10ML IV SOLN SH","80000007","CDM","0636","RC","99999-0037-74","NDC",,,"facility","outpatient","16.666666","ML","PN","0.0001","0.0001",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL BUDIGALIMAB (ABBV-181) 100MG IV SOLR SH","80000007","CDM","0636","RC","99999-0037-75","NDC",,,"facility","outpatient","3.000000","UN","PN","0.0025","0.0025",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","80000008","CDM","0250","RC","0409-2267-20","NDC",,,"facility","inpatient","20.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","80000008","CDM","0250","RC","0409-2339-34","NDC",,,"facility","inpatient","6.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","80000008","CDM","0250","RC","72266-102-01","NDC",,,"facility","inpatient","20.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN","80000037","CDM","0250","RC","J3490","HCPCS","14789-015-05","NDC","facility","inpatient","2.375000","ML",,"576","576",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN","80000037","CDM","0250","RC","J3490","HCPCS","14789-015-07","NDC","facility","inpatient","6.600000","ML",,"576","576",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","80000037","CDM","0250","RC","J3490","HCPCS","0517-4601-25","NDC","facility","inpatient","5.000000","ML",,"113.75","113.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN","80000037","CDM","0250","RC","J3490","HCPCS","0548-9502-00","NDC","facility","inpatient","1.666666","ML",,"240","240",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","80000037","CDM","0250","RC","J3490","HCPCS","42023-113-10","NDC","facility","inpatient","10.000000","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","80000037","CDM","0250","RC","J3490","HCPCS","70092-1119-44","NDC","facility","inpatient","14.375000","ML",,"104.41","104.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","80000037","CDM","0250","RC","J3490","HCPCS","69374-982-55","NDC","facility","inpatient","2.227272","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","80000037","CDM","0250","RC","0517-4601-25","NDC",,,"facility","inpatient","1.000000","ML",,"113.75","113.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN","80000037","CDM","0250","RC","14789-015-05","NDC",,,"facility","inpatient","5.789473","ML",,"2880","2880",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN","80000037","CDM","0250","RC","14789-015-07","NDC",,,"facility","inpatient","5.000000","ML",,"2880","2880",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","80000037","CDM","0250","RC","69374-982-55","NDC",,,"facility","inpatient","10.714285","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","80000037","CDM","0250","RC","70092-1119-44","NDC",,,"facility","inpatient","245.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL-SODIUM CHLORIDE 50-0.9 MG/5ML-% IV SOSY","80000037","CDM","0250","RC","70092-9119-44","NDC",,,"facility","inpatient","5.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL-SODIUM CHLORIDE 50-0.9 MG/5ML-% IV SOSY","80000037","CDM","0250","RC","71286-3022-1","NDC",,,"facility","inpatient","15.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","80000037","CDM","0636","RC","J3490","HCPCS","70092-1119-44","NDC","facility","outpatient","7.900000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","80000037","CDM","0636","RC","J3490","HCPCS","69374-982-55","NDC","facility","outpatient","4.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN","80000037","CDM","0636","RC","J3490","HCPCS","14789-015-05","NDC","facility","outpatient","1.106666","ML",,"567.99","567.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","80000037","CDM","0636","RC","J3490","HCPCS","0517-4601-25","NDC","facility","outpatient","3.000000","ML",,"113.75","113.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","80000037","CDM","0636","RC","0517-4601-25","NDC",,,"facility","outpatient","1.000000","ML",,"113.75","113.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN","80000037","CDM","0636","RC","14789-015-05","NDC",,,"facility","outpatient","5.000000","ML",,"2880","2880",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE 20MG/ML INTERMITTENT (PEDIATRIC) SH","81000000","CDM","0250","RC","J0613","HCPCS","44567-621-24","NDC","facility","inpatient","0.495238","ML",,"7.14","7.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS","81000000","CDM","0250","RC","J0750","HCPCS","60687-719-95","NDC","facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS","81000000","CDM","0250","RC","J0750","HCPCS","0904-7172-07","NDC","facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS","81000000","CDM","0250","RC","J0751","HCPCS","61958-2002-2","NDC","facility","inpatient","1.142857","UN",,"264.28","264.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS","81000000","CDM","0250","RC","J0751","HCPCS","61958-2002-1","NDC","facility","inpatient","1.000000","UN",,"264.28","264.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000000","CDM","0250","RC","J1939","HCPCS","72205-101-01","NDC","facility","inpatient","2.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000000","CDM","0250","RC","J1939","HCPCS","0641-6008-10","NDC","facility","inpatient","2.000000","ML",,"20.65","20.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000000","CDM","0250","RC","J1939","HCPCS","0641-6007-10","NDC","facility","inpatient","2.000000","ML",,"6.14","6.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 500MCG/ML ORAL SUSP (PEDIATRIC) SH","81000000","CDM","0250","RC","J3490","HCPCS","49884-065-01","NDC","facility","inpatient","2.333333","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 1 MG PO TABS","81000000","CDM","0250","RC","J3490","HCPCS","23155-606-01","NDC","facility","inpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 1 MG PO TABS","81000000","CDM","0250","RC","J3490","HCPCS","0904-6709-61","NDC","facility","inpatient","1.800000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 1 MG/5ML PO SOLN","81000000","CDM","0250","RC","J3490","HCPCS","49884-042-33","NDC","facility","inpatient","15.000000","ML",,"31.35","31.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IJ SOLN RADIOLOGY SH","81000000","CDM","0250","RC","J7030","HCPCS","0338-0049-04","NDC","facility","inpatient","105.000000","ML",,"10.19","10.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","81000000","CDM","0250","RC","J7040","HCPCS","0338-0049-03","NDC","facility","inpatient","30.000000","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","81000000","CDM","0250","RC","J7040","HCPCS","0338-0049-03","NDC","facility","inpatient","33.951219","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","81000000","CDM","0250","RC","J7050","HCPCS","0338-0049-02","NDC","facility","inpatient","30.000000","ML","PN","10.32","10.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR","81000000","CDM","0250","RC","J7519","HCPCS","71288-803-21","NDC","facility","inpatient","0.020630","UN","JZ","10.09","10.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR","81000000","CDM","0250","RC","J7519","HCPCS","71288-803-20","NDC","facility","inpatient","0.022981","UN","JZ","10.72","10.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR","81000000","CDM","0250","RC","J7519","HCPCS","0004-0298-09","NDC","facility","inpatient","0.020000","UN","JZ","13.93","13.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON 4 MG PO TBDP","81000000","CDM","0250","RC","Q0162","HCPCS","57237-077-10","NDC","facility","inpatient","1.000000","UN",,"10.08","10.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAFCILLIN 2 GM/100ML NS (MINIBAG)","81000000","CDM","0250","RC","S0032","HCPCS","55150-123-15","NDC","facility","inpatient","0.341923","UN",,"77.04","77.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAFCILLIN SODIUM 1 G IJ SOLR","81000000","CDM","0250","RC","S0032","HCPCS","44567-221-10","NDC","facility","inpatient","0.555714","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAFCILLIN SODIUM 1 G IJ SOLR","81000000","CDM","0250","RC","S0032","HCPCS","0781-3124-95","NDC","facility","inpatient","0.290000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 0.8 G PO PACK","81000000","CDM","0250","RC","Z7610","HCPCS","0115-1365-30","NDC","facility","inpatient","1.573348","UN",,"71.04","71.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 8 MG PO TBDP","81000000","CDM","0250","RC","Z7610","HCPCS","0378-7734-93","NDC","facility","inpatient","1.000000","UN",,"111.4","111.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 650 MG PO TABS","81000000","CDM","0250","RC","Z7610","HCPCS","0591-3720-30","NDC","facility","inpatient","1.000000","UN",,"27.5","27.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 50 MG PO CAPS","81000000","CDM","0250","RC","Z7610","HCPCS","0904-2056-61","NDC","facility","inpatient","1.000000","UN",,"10.08","10.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","Z7610","HCPCS","0904-5306-61","NDC","facility","inpatient","2.333333","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","Z7610","HCPCS","0904-5306-80","NDC","facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 50 MG PO CAPS","81000000","CDM","0250","RC","Z7610","HCPCS","0904-5307-80","NDC","facility","inpatient","1.857142","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","Z7610","HCPCS","0904-7237-61","NDC","facility","inpatient","1.859890","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 1 MG PO TABS","81000000","CDM","0250","RC","Z7610","HCPCS","23155-606-01","NDC","facility","inpatient","1.000000","UN",,"3.46","3.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOLVAPTAN 30 MG PO TABS","81000000","CDM","0250","RC","Z7610","HCPCS","31722-869-03","NDC","facility","inpatient","1.000000","UN",,"1465.5","1465.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000000","CDM","0250","RC","Z7610","HCPCS","42023-201-01","NDC","facility","inpatient","1.000000","UN",,"823.55","823.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOLVAPTAN 15 MG PO TABS","81000000","CDM","0250","RC","Z7610","HCPCS","49884-768-52","NDC","facility","inpatient","1.000000","UN",,"1423.56","1423.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 0.8 G PO PACK","81000000","CDM","0250","RC","Z7610","HCPCS","58468-0132-2","NDC","facility","inpatient","2.000000","UN",,"85.68","85.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOLVAPTAN 30 MG PO TABS","81000000","CDM","0250","RC","Z7610","HCPCS","59148-021-50","NDC","facility","inpatient","1.000000","UN",,"1618.93","1618.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000000","CDM","0250","RC","Z7610","HCPCS","63323-649-07","NDC","facility","inpatient","9.300000","UN",,"411.78","411.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 8 MG PO TBDP","81000000","CDM","0250","RC","Z7610","HCPCS","65862-391-10","NDC","facility","inpatient","2.142857","UN",,"81.02","81.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 0.8 G PO PACK","81000000","CDM","0250","RC","Z7610","HCPCS","65862-930-90","NDC","facility","inpatient","1.000000","UN",,"73.14","73.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","81000000","CDM","0250","RC","Z7610","HCPCS","68094-024-59","NDC","facility","inpatient","317.520000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 8 MG PO TBDP","81000000","CDM","0250","RC","Z7610","HCPCS","68462-158-40","NDC","facility","inpatient","1.000000","UN",,"115.49","115.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","81000000","CDM","0250","RC","Z7610","HCPCS","69339-152-17","NDC","facility","inpatient","12.311428","ML",,"2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 50 MG PO CAPS","81000000","CDM","0250","RC","Z7610","HCPCS","0904-2056-61","NDC","facility","inpatient","1.000000","UN","PN","10.08","10.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","Z7610","HCPCS","0904-7237-61","NDC","facility","inpatient","1.000000","UN","PN","6.48","6.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ONDANSETRON 8 MG PO TBDP","81000000","CDM","0250","RC","Z7610","HCPCS","65862-391-10","NDC","facility","inpatient","1.000000","UN","PN","111.4","111.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DULOXETINE HCL 20 MG PO CPEP","81000000","CDM","0250","RC","0002-3235-60","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 30 MG PO CPEP","81000000","CDM","0250","RC","0002-3240-30","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 60 MG PO CPEP","81000000","CDM","0250","RC","0002-3270-30","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 2.5 MG PO TABS","81000000","CDM","0250","RC","0002-4112-30","NDC",,,"facility","inpatient","1.000000","UN",,"59.39","59.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 5 MG PO TABS","81000000","CDM","0250","RC","0002-4115-30","NDC",,,"facility","inpatient","1.112676","UN",,"57.11","57.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 10 MG PO TABS","81000000","CDM","0250","RC","0002-4117-30","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BARICITINIB 2 MG PO TABS","81000000","CDM","0250","RC","0002-4182-30","NDC",,,"facility","inpatient","1.000000","UN",,"283.18","283.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 5 MG PO TBDP","81000000","CDM","0250","RC","0002-4453-85","NDC",,,"facility","inpatient","1.494117","UN",,"63.50","63.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 10 MG PO TBDP","81000000","CDM","0250","RC","0002-4454-85","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRASUGREL HCL 10 MG PO TABS","81000000","CDM","0250","RC","0002-5123-30","NDC",,,"facility","inpatient","1","EA",,"55.08","55.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 1.000000 TAB"
"APIXABAN 2.5 MG PO TABS","81000000","CDM","0250","RC","0003-0893-21","NDC",,,"facility","inpatient","1.042105","UN",,"53.11","53.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APIXABAN 2.5 MG PO TABS","81000000","CDM","0250","RC","0003-0893-31","NDC",,,"facility","inpatient","1.091533","UN",,"53.85","53.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APIXABAN 5 MG PO TABS","81000000","CDM","0250","RC","0003-0894-31","NDC",,,"facility","inpatient","1.083760","UN",,"51.70","51.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENTECAVIR 0.5 MG PO TABS","81000000","CDM","0250","RC","0003-1611-12","NDC",,,"facility","inpatient","2.333333","UN",,"164.7","164.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENTECAVIR 1 MG PO TABS","81000000","CDM","0250","RC","0003-1612-12","NDC",,,"facility","inpatient","1.000000","UN",,"164.7","164.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENTECAVIR 0.05 MG/ML PO SOLN","81000000","CDM","0250","RC","0003-1614-12","NDC",,,"facility","inpatient","209.995800","ML",,"430.53","430.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALGANCICLOVIR HCL 450 MG PO TABS","81000000","CDM","0250","RC","0004-0038-22","NDC",,,"facility","inpatient","1.000000","UN",,"318.25","318.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALGANCICLOVIR HCL 50 MG/ML PO SOLR","81000000","CDM","0250","RC","0004-0039-09","NDC",,,"facility","inpatient","2.725915","ML",,"258.46","258.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","81000000","CDM","0250","RC","0004-0800-85","NDC",,,"facility","inpatient","1.000000","UN",,"72.9","72.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","81000000","CDM","0250","RC","0004-0802-85","NDC",,,"facility","inpatient","1.666666","UN",,"66.88","66.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR","81000000","CDM","0250","RC","0004-0822-05","NDC",,,"facility","inpatient","60.000917","ML",,"124.78","124.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEKAS PLUS PO CHEW","81000000","CDM","0250","RC","0005-4528-90","NDC",,,"facility","inpatient","1.000000","UN",,"9","9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IVERMECTIN 3 MG PO TABS","81000000","CDM","0250","RC","0006-0032-20","NDC",,,"facility","inpatient","2.714285","UN",,"16.75","16.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SITAGLIPTIN PHOSPHATE 25 MG PO TABS","81000000","CDM","0250","RC","0006-0221-28","NDC",,,"facility","inpatient","1.000000","UN",,"91.68","91.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SITAGLIPTIN PHOSPHATE 25 MG PO TABS","81000000","CDM","0250","RC","0006-0221-31","NDC",,,"facility","inpatient","1.000000","UN",,"91.68","91.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RALTEGRAVIR POTASSIUM 400 MG PO TABS","81000000","CDM","0250","RC","0006-0227-61","NDC",,,"facility","inpatient","1.000000","UN",,"117.55","117.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMVASTATIN 10 MG PO TABS","81000000","CDM","0250","RC","0006-0735-31","NDC",,,"facility","inpatient","1.000000","UN",,"28.50","28.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMVASTATIN 20 MG PO TABS","81000000","CDM","0250","RC","0006-0740-54","NDC",,,"facility","inpatient","1.000000","UN",,"53.2","53.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 50 MG PO TABS","81000000","CDM","0250","RC","0006-0952-54","NDC",,,"facility","inpatient","1.000000","UN",,"20.65","20.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORAVIRINE 100 MG PO TABS","81000000","CDM","0250","RC","0006-3069-01","NDC",,,"facility","inpatient","1.000000","UN",,"211.28","211.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROTHIAZIDE 250 MG/5ML PO SUSP","81000000","CDM","0250","RC","0006-3239-66","NDC",,,"facility","inpatient","1.000000","ML",,"13.12","13.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL 2 % OP SOLN","81000000","CDM","0250","RC","0006-3519-36","NDC",,,"facility","inpatient","23.333333","ML",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUGAMMADEX SODIUM 200 MG/2ML IV SOLN","81000000","CDM","0250","RC","0006-5423-12","NDC",,,"facility","inpatient","2.000000","ML","RISK","505.67","505.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"SUGAMMADEX SODIUM 200 MG/2ML IV SOLN","81000000","CDM","0250","RC","0006-5423-12","NDC",,,"facility","inpatient","2.296627","ML",,"831.28","831.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 3.125 MG PO TABS","81000000","CDM","0250","RC","0007-4139-20","NDC",,,"facility","inpatient","1.000000","UN",,"39.55","39.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 6.25 MG PO TABS","81000000","CDM","0250","RC","0007-4140-20","NDC",,,"facility","inpatient","1.240000","UN",,"30.17","30.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 12.5 MG PO TABS","81000000","CDM","0250","RC","0007-4141-20","NDC",,,"facility","inpatient","2.037037","UN",,"39.90","39.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 25 MG PO TABS","81000000","CDM","0250","RC","0007-4142-20","NDC",,,"facility","inpatient","1.500000","UN",,"40.35","40.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL ER 75 MG PO CP24","81000000","CDM","0250","RC","0008-0833-22","NDC",,,"facility","inpatient","1.000000","UN",,"92","92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL ER 150 MG PO CP24","81000000","CDM","0250","RC","0008-0836-22","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","81000000","CDM","0250","RC","0008-0841-81","NDC",,,"facility","inpatient","1.026845","UN",,"69.48","69.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","81000000","CDM","0250","RC","0008-0843-81","NDC",,,"facility","inpatient","9.000000","UN",,"69.48","69.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 5 MG PO TABS","81000000","CDM","0250","RC","0009-0012-01","NDC",,,"facility","inpatient","1.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 1MG/ML ORAL LIQD (PEDIATRIC) SH","81000000","CDM","0250","RC","0009-0031-01","NDC",,,"facility","inpatient","1.000000","ML",,"10.5","10.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 0.5 MG PO TABS","81000000","CDM","0250","RC","0009-0055-01","NDC",,,"facility","inpatient","1.000000","UN",,"32.5","32.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 1 MG PO TABS","81000000","CDM","0250","RC","0009-0090-01","NDC",,,"facility","inpatient","1.000000","UN",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GELATIN ABSORBABLE 12-7 MM EX MISC","81000000","CDM","0250","RC","0009-0315-08","NDC",,,"facility","inpatient","1.011730","EA",,"53.39","53.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GELATIN ABSORBABLE 100 EX MISC","81000000","CDM","0250","RC","0009-0342-01","NDC",,,"facility","inpatient","1.121212","EA",,"158.77","158.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GELATIN ABSORBABLE MT POWD","81000000","CDM","0250","RC","0009-0433-04","NDC",,,"facility","inpatient","1.000000","GR",,"289.04","289.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN","81000000","CDM","0250","RC","0009-0856-08","NDC",,,"facility","inpatient","1.000000","ML",,"945","945",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN PHOSPHATE 2 % VA CREA","81000000","CDM","0250","RC","0009-3448-01","NDC",,,"facility","inpatient","40.000000","GM",,"806.14","806.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINEZOLID 600 MG PO TABS","81000000","CDM","0250","RC","0009-5138-03","NDC",,,"facility","inpatient","1.000000","UN",,"41.47","41.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 100MG/ML SOLN FOR HEMOPTYSIS SH (PEDIATRIC)(NEBULIZATION USE)","81000000","CDM","0250","RC","0013-1114-10","NDC",,,"facility","inpatient","90.000000","ML",,"85.68","85.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000000","CDM","0250","RC","0013-1114-21","NDC",,,"facility","inpatient","10.000000","ML",,"168","168",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LATANOPROST 0.005 % OP SOLN","81000000","CDM","0250","RC","0013-8303-04","NDC",,,"facility","inpatient","3.214285","ML",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARTIFICIAL TEARS OP OINT - CONSOLIDATED","81000000","CDM","0250","RC","0023-0240-04","NDC",,,"facility","inpatient","4.099099","GM",,"2.10","2.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARTIFICIAL TEARS OP OINT - CONSOLIDATED","81000000","CDM","0250","RC","0023-0312-04","NDC",,,"facility","inpatient","3.500000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOXYMETHYLCELLULOSE SODIUM 0.5 % OP SOLN","81000000","CDM","0250","RC","0023-0798-15","NDC",,,"facility","inpatient","13.756015","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC TROMETHAMINE 0.5 % OP SOLN","81000000","CDM","0250","RC","0023-2181-05","NDC",,,"facility","inpatient","5.000000","ML",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BIMATOPROST 0.01 % OP SOLN","81000000","CDM","0250","RC","0023-3205-03","NDC",,,"facility","inpatient","2.500000","ML",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 15000-47000 UNITS PO CPEP","81000000","CDM","0250","RC","0023-6111-01","NDC",,,"facility","inpatient","1.000000","UN",,"27.5","27.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 20000-63000 UNITS PO CPEP","81000000","CDM","0250","RC","0023-6112-01","NDC",,,"facility","inpatient","1.000000","UN",,"27.85","27.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG PO TABS","81000000","CDM","0250","RC","0024-1596-01","NDC",,,"facility","inpatient","1.400000","UN",,"13.50","13.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DRONEDARONE HCL 400 MG PO TABS","81000000","CDM","0250","RC","0024-4142-60","NDC",,,"facility","inpatient","1.069565","UN",,"63.17","63.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CELECOXIB 100 MG PO CAPS","81000000","CDM","0250","RC","0025-1520-34","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CELECOXIB 200 MG PO CAPS","81000000","CDM","0250","RC","0025-1525-31","NDC",,,"facility","inpatient","1.000000","UN",,"78.8","78.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPLERENONE 50 MG PO TABS","81000000","CDM","0250","RC","0025-1720-03","NDC",,,"facility","inpatient","1.000000","UN",,"70.97","70.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 12000-38000 UNITS PO CPEP","81000000","CDM","0250","RC","0032-0047-70","NDC",,,"facility","inpatient","1.000000","UN",,"21.49","21.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 3000-9500 UNITS PO CPEP","81000000","CDM","0250","RC","0032-1203-70","NDC",,,"facility","inpatient","1.285714","UN",,"11.58","11.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS PO CPEP","81000000","CDM","0250","RC","0032-1206-01","NDC",,,"facility","inpatient","1.016666","UN",,"14.05","14.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 12000-38000 UNITS PO CPEP","81000000","CDM","0250","RC","0032-1212-01","NDC",,,"facility","inpatient","1.056701","UN",,"21.29","21.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS PO CPEP","81000000","CDM","0250","RC","0032-1224-01","NDC",,,"facility","inpatient","1.099231","UN",,"39.97","39.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS PO CPEP","81000000","CDM","0250","RC","0032-2636-01","NDC",,,"facility","inpatient","1.096138","UN",,"38.56","38.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARISOPRODOL 350 MG PO TABS","81000000","CDM","0250","RC","0037-2001-01","NDC",,,"facility","inpatient","1.000000","UN",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORT-PRAMOXINE (PERIANAL) 1-1 % EX FOAM","81000000","CDM","0250","RC","0037-6822-10","NDC",,,"facility","inpatient","10.000000","GR",,"888.56","888.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESTROGENS CONJUGATED 0.625 MG/GM VA CREA","81000000","CDM","0250","RC","0046-0872-21","NDC",,,"facility","inpatient","54.000000","GR",,"1620.18","1620.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 20 MG/ML PO CONC","81000000","CDM","0250","RC","0049-0050-01","NDC",,,"facility","inpatient","60.000000","ML",,"58.58","58.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZIPRASIDONE HCL 20 MG PO CAPS","81000000","CDM","0250","RC","0049-0352-60","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","0049-3180-30","NDC",,,"facility","inpatient","1.000000","UN",,"24.57","24.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","0049-3430-30","NDC",,,"facility","inpatient","1.000000","UN",,"225.33","225.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 10MG/ML ORAL SUSP (PEDIATRIC) SH","81000000","CDM","0250","RC","0049-3440-19","NDC",,,"facility","inpatient","34.999300","ML",,"16.06","16.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 40 MG/ML PO SUSR","81000000","CDM","0250","RC","0049-3450-19","NDC",,,"facility","inpatient","37.718666","ML",,"41.82","41.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","0049-4900-30","NDC",,,"facility","inpatient","1.320000","UN",,"56.32","56.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","0049-4910-30","NDC",,,"facility","inpatient","1.000000","UN",,"68.76","68.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0049-4960-30","NDC",,,"facility","inpatient","1.000000","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLECAINIDE ACETATE 50 MG PO TABS","81000000","CDM","0250","RC","0054-0010-20","NDC",,,"facility","inpatient","1.000000","UN",,"14.79","14.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLECAINIDE ACETATE 50 MG PO TABS","81000000","CDM","0250","RC","0054-0010-21","NDC",,,"facility","inpatient","1.000000","UN",,"11.89","11.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLECAINIDE ACETATE 100 MG PO TABS","81000000","CDM","0250","RC","0054-0011-20","NDC",,,"facility","inpatient","1.052307","UN",,"19.24","19.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLECAINIDE ACETATE 100 MG PO TABS","81000000","CDM","0250","RC","0054-0011-25","NDC",,,"facility","inpatient","1.000000","UN",,"19.69","19.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CITALOPRAM HYDROBROMIDE 10 MG/5ML PO SOLN","81000000","CDM","0250","RC","0054-0062-58","NDC",,,"facility","inpatient","240.038406","ML",,"31.85","31.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE 2MG/ML ORAL LIQD (PEDIATRIC) SH","81000000","CDM","0250","RC","0054-0237-63","NDC",,,"facility","inpatient","500.000000","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE-SALMETEROL 100-50 MCG/ACT IN AEPB","81000000","CDM","0250","RC","0054-0326-56","NDC",,,"facility","inpatient","59.988002","EA",,"39.16","39.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POSACONAZOLE 40 MG/ML PO SUSP","81000000","CDM","0250","RC","0054-0449-49","NDC",,,"facility","inpatient","104.997900","ML",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 10 MG/5ML PO SOLN","81000000","CDM","0250","RC","0054-0622-63","NDC",,,"facility","inpatient","473.036896","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","0054-0748-25","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LITHIUM CARBONATE 150 MG PO CAPS","81000000","CDM","0250","RC","0054-2526-25","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LITHIUM CARBONATE 600 MG PO CAPS","81000000","CDM","0250","RC","0054-2531-25","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML PO LIQD","81000000","CDM","0250","RC","0054-3194-46","NDC",,,"facility","inpatient","60.001827","ML",,"62.98","62.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP","81000000","CDM","0250","RC","0054-3270-99","NDC",,,"facility","inpatient","18.752688","GR",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE 1MG/ML ORAL SYRINGE (NEONATAL) SH","81000000","CDM","0250","RC","0054-3555-63","NDC",,,"facility","inpatient","507.161678","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 20 MG/5ML PO SOLN","81000000","CDM","0250","RC","0054-3727-63","NDC",,,"facility","inpatient","500.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 20 MG PO TABS","81000000","CDM","0250","RC","0054-4297-31","NDC",,,"facility","inpatient","1.084210","UN",,"11.15","11.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MERCAPTOPURINE 25MG PO PRE-SPLIT TABS SH","81000000","CDM","0250","RC","0054-4581-27","NDC",,,"facility","inpatient","0.500000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 10 MG MT TROC","81000000","CDM","0250","RC","0054-8146-22","NDC",,,"facility","inpatient","1.010065","UN",,"18.89","18.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 20 MG PO TABS","81000000","CDM","0250","RC","0054-8297-25","NDC",,,"facility","inpatient","1.132681","UN",,"11.01","11.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 40 MG PO TABS","81000000","CDM","0250","RC","0054-8299-25","NDC",,,"facility","inpatient","1.055192","UN",,"12.86","12.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 80 MG PO TABS","81000000","CDM","0250","RC","0054-8301-25","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEUCOVORIN CALCIUM 5 MG PO TABS","81000000","CDM","0250","RC","0054-8496-19","NDC",,,"facility","inpatient","1.200000","UN",,"18.2","18.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LITHIUM CARBONATE 150 MG PO CAPS","81000000","CDM","0250","RC","0054-8526-25","NDC",,,"facility","inpatient","1.114285","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LITHIUM CARBONATE 300 MG PO CAPS","81000000","CDM","0250","RC","0054-8527-25","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LITHIUM CARBONATE 300 MG PO TABS","81000000","CDM","0250","RC","0054-8528-25","NDC",,,"facility","inpatient","1.375000","UN",,"10.31","10.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 0.5MG PO PRE-SPLIT TABS SH","81000000","CDM","0250","RC","0056-0169-70","NDC",,,"facility","inpatient","0.500000","UN",,"12.41","12.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 5 MG PO TABS","81000000","CDM","0250","RC","0056-0172-70","NDC",,,"facility","inpatient","1.000000","UN",,"15.27","15.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCOSE 40 % PO GEL","81000000","CDM","0250","RC","00574-06915","NDC",,,"facility","inpatient","41.911764","ML",,"1.82","1.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCOSE 40 % PO GEL","81000000","CDM","0250","RC","00574-06930","NDC",,,"facility","inpatient","43.114961","ML",,"1.71","1.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBACHOL 0.01 % IO SOLN","81000000","CDM","0250","RC","0065-0023-15","NDC",,,"facility","inpatient","2.142857","ML",,"311.76","311.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BRINZOLAMIDE 1 % OP SUSP","81000000","CDM","0250","RC","0065-0275-10","NDC",,,"facility","inpatient","10.000000","ML",,"1235.64","1235.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN","81000000","CDM","0250","RC","0065-0359-02","NDC",,,"facility","inpatient","2.064257","ML",,"208.45","208.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPENTOLATE HCL 0.5 % OP SOLN","81000000","CDM","0250","RC","0065-0395-15","NDC",,,"facility","inpatient","15.000000","ML",,"436.62","436.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPENTOLATE HCL 1 % OP SOLN","81000000","CDM","0250","RC","0065-0396-02","NDC",,,"facility","inpatient","2.274509","ML",,"197.02","197.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPENTOLATE HCL 1 % OP SOLN","81000000","CDM","0250","RC","0065-0396-05","NDC",,,"facility","inpatient","8.500000","ML",,"345.26","345.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POVIDONE-IODINE 5 % OP SOLN","81000000","CDM","0250","RC","0065-0411-30","NDC",,,"facility","inpatient","30.000000","ML","RISK","102.45","102.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"POVIDONE-IODINE 5 % OP SOLN","81000000","CDM","0250","RC","0065-0411-30","NDC",,,"facility","inpatient","33.436754","ML",,"94.42","94.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARTIFICIAL TEARS OP OINT - CONSOLIDATED","81000000","CDM","0250","RC","0065-0518-01","NDC",,,"facility","inpatient","3.581159","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EYE STREAM OP SOLN","81000000","CDM","0250","RC","0065-0530-01","NDC",,,"facility","inpatient","47.142857","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 0.3 % OP SOLN","81000000","CDM","0250","RC","0065-0643-05","NDC",,,"facility","inpatient","5.000000","ML",,"489.92","489.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 0.3 % OP OINT","81000000","CDM","0250","RC","0065-0644-35","NDC",,,"facility","inpatient","3.500000","GM",,"519.50","519.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP","81000000","CDM","0250","RC","0065-0647-25","NDC",,,"facility","inpatient","1","EA",,"367.74","367.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 3.500000 APPLICATION"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT","81000000","CDM","0250","RC","0065-0648-35","NDC",,,"facility","inpatient","3.951612","GM",,"1072.79","1072.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"APRACLONIDINE HCL 1 % OP SOLN","81000000","CDM","0250","RC","0065-0660-10","NDC",,,"facility","inpatient","1.307692","EA",,"99.83","99.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TETRACAINE HCL 0.5 % OP SOLN","81000000","CDM","0250","RC","0065-0741-14","NDC",,,"facility","inpatient","4.311111","ML",,"73.34","73.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MOXIFLOXACIN HCL 0.5 % OP SOLN","81000000","CDM","0250","RC","0065-4013-03","NDC",,,"facility","inpatient","13.093457","ML",,"826.88","826.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP","81000000","CDM","0250","RC","0065-8533-02","NDC",,,"facility","inpatient","7.500000","ML",,"1195.65","1195.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICLOFENAC SODIUM 1 % EX GEL","81000000","CDM","0250","RC","0067-8152-03","NDC",,,"facility","inpatient","100.000000","GR",,"81.5","81.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIFAMPIN 600 MG/10ML IV (WET SOLR VIAL)","81000000","CDM","0250","RC","0068-0597-01","NDC",,,"facility","inpatient","1.000000","UN",,"762.55","762.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILDENAFIL CITRATE 10 MG/ML PO SUSR","81000000","CDM","0250","RC","0069-0336-21","NDC",,,"facility","inpatient","111.982082","ML",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIRMATRELVIR & RITONAVIR (EGFR 60ML/MIN AND GREATER) 20 X 150 MG & 10 X 100MG PO TBPK","81000000","CDM","0250","RC","0069-0345-30","NDC",,,"facility","inpatient","78.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIRMATRELVIR & RITONAVIR (EGFR 30-59 ML/MIN) 10 X 150 MG & 10 X 100MG PO TBPK","81000000","CDM","0250","RC","0069-1101-20","NDC",,,"facility","inpatient","20.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMLODIPINE BESYLATE 5 MG PO TABS","81000000","CDM","0250","RC","0069-1530-41","NDC",,,"facility","inpatient","1.208695","UN",,"42.38","42.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMLODIPINE BESYLATE 10 MG PO TABS","81000000","CDM","0250","RC","0069-1540-68","NDC",,,"facility","inpatient","1.000000","UN",,"53.65","53.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 200 MG/5ML PO SUSR","81000000","CDM","0250","RC","0069-3140-19","NDC",,,"facility","inpatient","1.538176","ML",,"10.30","10.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 250 MG PO TABS","81000000","CDM","0250","RC","0069-4061-89","NDC",,,"facility","inpatient","1.190476","UN",,"18.95","18.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIRMATRELVIR & RITONAVIR (EGFR 60ML/MIN AND GREATER) 20 X 150 MG & 10 X 100MG PO TBPK","81000000","CDM","0250","RC","0069-5321-03","NDC",,,"facility","inpatient","5.181818","UN",,"512.69","512.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIRMATRELVIR & RITONAVIR (EGFR 60ML/MIN AND GREATER) 20 X 150 MG & 10 X 100MG PO TBPK","81000000","CDM","0250","RC","0069-5321-30","NDC",,,"facility","inpatient","30.000000","UN",,"4170","4170",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOFETILIDE 125 MCG PO CAPS","81000000","CDM","0250","RC","0069-5800-43","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYTOIN 50 MG PO CHEW","81000000","CDM","0250","RC","0071-0007-40","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 10 MG PO TABS","81000000","CDM","0250","RC","0071-0155-23","NDC",,,"facility","inpatient","1.000000","UN",,"56.57","56.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 20 MG PO TABS","81000000","CDM","0250","RC","0071-0156-23","NDC",,,"facility","inpatient","1.000000","UN",,"79.29","79.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 40 MG PO TABS","81000000","CDM","0250","RC","0071-0157-23","NDC",,,"facility","inpatient","1.261818","UN",,"74.03","74.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 80 MG PO TABS","81000000","CDM","0250","RC","0071-0158-23","NDC",,,"facility","inpatient","1.166666","UN",,"83.36","83.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS","81000000","CDM","0250","RC","0071-0369-40","NDC",,,"facility","inpatient","1.000000","UN",,"11.36","11.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG SL SUBL","81000000","CDM","0250","RC","0071-0418-13","NDC",,,"facility","inpatient","27.272727","UN",,"238.63","238.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 600 MG PO TABS","81000000","CDM","0250","RC","0071-0513-24","NDC",,,"facility","inpatient","1.000000","UN",,"64.93","64.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 300 MG PO CAPS","81000000","CDM","0250","RC","0071-0805-24","NDC",,,"facility","inpatient","1.111111","UN",,"45.00","45.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 25 MG PO CAPS","81000000","CDM","0250","RC","0071-1012-68","NDC",,,"facility","inpatient","1.000000","UN",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 50 MG PO CAPS","81000000","CDM","0250","RC","0071-1013-68","NDC",,,"facility","inpatient","1.000000","UN",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 75 MG PO CAPS","81000000","CDM","0250","RC","0071-1014-68","NDC",,,"facility","inpatient","1.000000","UN",,"58.75","58.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 100 MG PO CAPS","81000000","CDM","0250","RC","0071-1015-68","NDC",,,"facility","inpatient","1.000000","UN",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 20 MG/ML PO SOLN","81000000","CDM","0250","RC","0071-1020-01","NDC",,,"facility","inpatient","473.000613","ML",,"59.63","59.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 250 MG/5ML PO SOLN","81000000","CDM","0250","RC","0071-2012-23","NDC",,,"facility","inpatient","568.778979","ML",,"27.38","27.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENETOCLAX 10 MG PO TABS","81000000","CDM","0250","RC","0074-0561-11","NDC",,,"facility","inpatient","1.000000","UN",,"99.22","99.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENETOCLAX 10 MG PO TABS","81000000","CDM","0250","RC","0074-0561-14","NDC",,,"facility","inpatient","1.000000","UN",,"99.23","99.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENETOCLAX 50 MG PO TABS","81000000","CDM","0250","RC","0074-0566-11","NDC",,,"facility","inpatient","1.547945","UN",,"460.10","460.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENETOCLAX 100 MG PO TABS","81000000","CDM","0250","RC","0074-0576-11","NDC",,,"facility","inpatient","1.110091","UN",,"543.27","543.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENETOCLAX 100 MG PO TABS","81000000","CDM","0250","RC","0074-0576-30","NDC",,,"facility","inpatient","1.000000","UN",,"459.79","459.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENOFIBRATE 145 MG PO TABS","81000000","CDM","0250","RC","0074-3189-90","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RITONAVIR 100 MG PO TABS","81000000","CDM","0250","RC","0074-3333-30","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM ER 250 MG PO TB24","81000000","CDM","0250","RC","0074-3826-13","NDC",,,"facility","inpatient","1.000000","UN",,"23.08","23.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE (PF) 10 MG/5ML IV SOLN","81000000","CDM","0250","RC","0074-4378-05","NDC",,,"facility","inpatient","5.000000","ML",,"107.44","107.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 50 MCG PO TABS","81000000","CDM","0250","RC","0074-4552-11","NDC",,,"facility","inpatient","1.000000","UN",,"14.02","14.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 75 MCG PO TABS","81000000","CDM","0250","RC","0074-5182-11","NDC",,,"facility","inpatient","1.250000","UN",,"14.08","14.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM 125 MG PO CSDR","81000000","CDM","0250","RC","0074-6114-13","NDC",,,"facility","inpatient","1.000000","UN",,"11.44","11.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM 125 MG PO TBEC","81000000","CDM","0250","RC","0074-6212-13","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG PO TABS","81000000","CDM","0250","RC","0074-6624-11","NDC",,,"facility","inpatient","1.235294","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXCARBAZEPINE 300 MG/5ML PO SUSP","81000000","CDM","0250","RC","0078-0357-52","NDC",,,"facility","inpatient","250.000000","ML",,"171.98","171.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALSARTAN 80 MG PO TABS","81000000","CDM","0250","RC","0078-0358-34","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALSARTAN 160 MG PO TABS","81000000","CDM","0250","RC","0078-0359-34","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALSARTAN 40 MG PO TABS","81000000","CDM","0250","RC","0078-0423-15","NDC",,,"facility","inpatient","5.000000","UN",,"27.30","27.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPHENIDATE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0078-0440-05","NDC",,,"facility","inpatient","1.000000","UN",,"20","20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SACUBITRIL-VALSARTAN 24-26 MG PO TABS","81000000","CDM","0250","RC","0078-0659-20","NDC",,,"facility","inpatient","1.254295","UN",,"53.19","53.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SACUBITRIL-VALSARTAN 24-26 MG PO TABS","81000000","CDM","0250","RC","0078-0659-67","NDC",,,"facility","inpatient","1.220858","UN",,"50.52","50.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SACUBITRIL-VALSARTAN 97-103 MG PO TABS","81000000","CDM","0250","RC","0078-0696-20","NDC",,,"facility","inpatient","1.253164","UN",,"55.04","55.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SACUBITRIL-VALSARTAN 97-103 MG PO TABS","81000000","CDM","0250","RC","0078-0696-67","NDC",,,"facility","inpatient","1.000000","UN",,"55.00","55.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDOSTAURIN 25 MG PO CAPS","81000000","CDM","0250","RC","0078-0698-02","NDC",,,"facility","inpatient","1.000000","UN",,"800","800",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BRINZOLAMIDE 1 % OP SUSP","81000000","CDM","0250","RC","0078-0722-10","NDC",,,"facility","inpatient","50.000000","ML",,"1323.36","1323.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SACUBITRIL-VALSARTAN 49-51 MG PO TABS","81000000","CDM","0250","RC","0078-0777-20","NDC",,,"facility","inpatient","1.054054","UN",,"55.03","55.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 0.3 % OP OINT","81000000","CDM","0250","RC","0078-0813-01","NDC",,,"facility","inpatient","3.500000","GR",,"1194.57","1194.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 0.3 % OP OINT","81000000","CDM","0250","RC","0078-0841-01","NDC",,,"facility","inpatient","8.166666","GR",,"1187.33","1187.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT","81000000","CDM","0250","RC","0078-0876-01","NDC",,,"facility","inpatient","3.500000","GR",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 0.1 % OP SUSP","81000000","CDM","0250","RC","0078-0925-25","NDC",,,"facility","inpatient","5.000000","ML",,"417.68","417.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYSPORIN 500-10000 UNIT/GM EX OINT","81000000","CDM","0250","RC","0081-0798-87","NDC",,,"facility","inpatient","1.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT","81000000","CDM","0250","RC","0081-0798-88","NDC",,,"facility","inpatient","14.200000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLECALCIFEROL 10 MCG/ML PO LIQD","81000000","CDM","0250","RC","0087-0866-44","NDC",,,"facility","inpatient","52.248258","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WATER ORAL PO LIQD","81000000","CDM","0250","RC","0087-5102-42","NDC",,,"facility","inpatient","236.999396","ML",,"0.74","0.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 3.125 MG PO TABS","81000000","CDM","0250","RC","0093-0051-01","NDC",,,"facility","inpatient","1.074136","UN",,"13.17","13.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZOLPIDEM TARTRATE 5 MG PO TABS","81000000","CDM","0250","RC","0093-0073-01","NDC",,,"facility","inpatient","1.000000","UN",,"33.66","33.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL 30 MG PO TABS","81000000","CDM","0250","RC","0093-0318-01","NDC",,,"facility","inpatient","1.090909","UN",,"10.10","10.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL 60 MG PO TABS","81000000","CDM","0250","RC","0093-0319-01","NDC",,,"facility","inpatient","1.000000","UN",,"9.53","9.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL 90 MG PO TABS","81000000","CDM","0250","RC","0093-0320-01","NDC",,,"facility","inpatient","1.000011","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATENOLOL 25 MG PO TABS","81000000","CDM","0250","RC","0093-0787-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORTRIPTYLINE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","0093-0810-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORTRIPTYLINE HCL 50 MG PO CAPS","81000000","CDM","0250","RC","0093-0812-01","NDC",,,"facility","inpatient","1.000000","UN",,"15.21","15.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORTRIPTYLINE HCL 75 MG PO CAPS","81000000","CDM","0250","RC","0093-0813-01","NDC",,,"facility","inpatient","1.000000","UN",,"23.2","23.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 0.5 MG PO TABS","81000000","CDM","0250","RC","0093-0832-01","NDC",,,"facility","inpatient","1.842105","UN",,"28.57","28.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN V POTASSIUM 500 MG PO TABS","81000000","CDM","0250","RC","0093-1174-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOMYCIN SULFATE 500 MG PO TABS","81000000","CDM","0250","RC","0093-1177-01","NDC",,,"facility","inpatient","1.000000","UN",,"8.18","8.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0093-2203-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0093-2204-01","NDC",,,"facility","inpatient","1.176211","UN",,"13.45","13.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 250 MG PO CHEW","81000000","CDM","0250","RC","0093-2268-01","NDC",,,"facility","inpatient","1.000000","UN",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS","81000000","CDM","0250","RC","0093-2274-34","NDC",,,"facility","inpatient","1.000000","UN",,"20.82","20.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","81000000","CDM","0250","RC","0093-2275-34","NDC",,,"facility","inpatient","1.280000","UN",,"26.76","26.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICLOXACILLIN SODIUM 250 MG PO CAPS","81000000","CDM","0250","RC","0093-3123-01","NDC",,,"facility","inpatient","1.000000","UN",,"8.26","8.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICLOXACILLIN SODIUM 500 MG PO CAPS","81000000","CDM","0250","RC","0093-3125-01","NDC",,,"facility","inpatient","1.000000","UN",,"15.02","15.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","81000000","CDM","0250","RC","0093-3174-31","NDC",,,"facility","inpatient","8.500000","GR",,"370.09","370.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 1 MG PO TABS","81000000","CDM","0250","RC","0093-3212-01","NDC",,,"facility","inpatient","1.000000","UN",,"35.29","35.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOBENZAPRINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0093-3422-01","NDC",,,"facility","inpatient","1.026966","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 1 MG PO TABS","81000000","CDM","0250","RC","0093-3426-01","NDC",,,"facility","inpatient","1.032000","UN",,"27.12","27.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PEG-KCL-NACL-NASULF-NA ASC-C 100 G PO SOLR","81000000","CDM","0250","RC","0093-3560-26","NDC",,,"facility","inpatient","1.390243","UN",,"322.20","322.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR","81000000","CDM","0250","RC","0093-4127-73","NDC",,,"facility","inpatient","100.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","0093-4155-73","NDC",,,"facility","inpatient","100.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","0093-4155-79","NDC",,,"facility","inpatient","100.502696","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","0093-4177-73","NDC",,,"facility","inpatient","100.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 5 MG PO TBDP","81000000","CDM","0250","RC","0093-5245-65","NDC",,,"facility","inpatient","1.000000","UN","PN","57.1","57.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"OLANZAPINE 5 MG PO TBDP","81000000","CDM","0250","RC","0093-5245-65","NDC",,,"facility","inpatient","1.151067","UN",,"52.32","52.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAVASTATIN SODIUM 20 MG PO TABS","81000000","CDM","0250","RC","0093-7201-98","NDC",,,"facility","inpatient","2.333333","UN",,"17.23","17.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAVASTATIN SODIUM 40 MG PO TABS","81000000","CDM","0250","RC","0093-7202-98","NDC",,,"facility","inpatient","1.000000","UN",,"26.37","26.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 12.5 MG PO TABS","81000000","CDM","0250","RC","0093-7295-01","NDC",,,"facility","inpatient","1.164948","UN",,"13.68","13.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MONTELUKAST SODIUM 10 MG PO TABS","81000000","CDM","0250","RC","0093-7426-98","NDC",,,"facility","inpatient","1.000000","UN",,"31.11","31.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOZAPINE 100 MG PO TABS","81000000","CDM","0250","RC","0093-7772-93","NDC",,,"facility","inpatient","1.000000","UN",,"13.71","13.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMCICLOVIR 500 MG PO TABS","81000000","CDM","0250","RC","0093-8119-56","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 0.25 MG PO TBDP","81000000","CDM","0250","RC","0093-9291-19","NDC",,,"facility","inpatient","1.000000","UN",,"23.12","23.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA 10-100 MG PO TABS","81000000","CDM","0250","RC","0093-9701-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 1 % EX LOTN","81000000","CDM","0250","RC","0096-0732-04","NDC",,,"facility","inpatient","120.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPYRIDAMOLE 75 MG PO TABS","81000000","CDM","0250","RC","0115-1072-01","NDC",,,"facility","inpatient","1.000000","UN",,"16.84","16.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 0.8 G PO PACK","81000000","CDM","0250","RC","0115-1365-30","NDC",,,"facility","inpatient","1.278674","UN",,"64.89","64.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 40 MG PO TABS","81000000","CDM","0250","RC","0115-1661-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERBUTALINE SULFATE 5 MG PO TABS","81000000","CDM","0250","RC","0115-2622-01","NDC",,,"facility","inpatient","1.000000","UN",,"33.50","33.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOSTIGMINE BROMIDE 60 MG PO TABS","81000000","CDM","0250","RC","0115-3511-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PILOCARPINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0115-5922-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN","81000000","CDM","0250","RC","0116-2001-89","NDC",,,"facility","inpatient","15.000017","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE 10 GM/15ML PO SOLN","81000000","CDM","0250","RC","0116-4005-30","NDC",,,"facility","inpatient","37.643312","ML",,"22.03","22.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","81000000","CDM","0250","RC","0121-0431-30","NDC",,,"facility","inpatient","33.653048","ML",,"1.98","1.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN-CODEINE 120-12 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-0504-05","NDC",,,"facility","inpatient","5.000000","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERROUS SULFATE 300 (60 FE) MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-0530-05","NDC",,,"facility","inpatient","5.000000","ML",,"1.6","1.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 150 MG/15ML PO LIQD","81000000","CDM","0250","RC","0121-0544-10","NDC",,,"facility","inpatient","10.000000","ML",,"1.33","1.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROMETHAZINE-CODEINE 6.25-10 MG/5ML PO SYRP","81000000","CDM","0250","RC","0121-0547-05","NDC",,,"facility","inpatient","5.000000","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE (ENULOSE) ENEMA SH","81000000","CDM","0250","RC","0121-0577-08","NDC",,,"facility","inpatient","237.000521","ML",,"23.1","23.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE (ENULOSE) ENEMA SH","81000000","CDM","0250","RC","0121-0577-16","NDC",,,"facility","inpatient","472.999605","ML",,"87.6","87.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HALOPERIDOL LACTATE 2 MG/ML PO CONC","81000000","CDM","0250","RC","0121-0581-05","NDC",,,"facility","inpatient","6.023622","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMANTADINE HCL 50 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-0646-10","NDC",,,"facility","inpatient","10.000000","ML",,"22.11","22.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCRALFATE 1 GM/10ML PO SUSP","81000000","CDM","0250","RC","0121-0747-00","NDC",,,"facility","inpatient","10.256690","ML",,"64.92","64.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-0775-04","NDC",,,"facility","inpatient","118.008024","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 125 MG PO CAPS","81000000","CDM","0250","RC","0121-0867-20","NDC",,,"facility","inpatient","1.200000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/ML MT SUSP","81000000","CDM","0250","RC","0121-0868-05","NDC",,,"facility","inpatient","5.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE (ENULOSE) ENEMA SH","81000000","CDM","0250","RC","0121-0873-16","NDC",,,"facility","inpatient","520.900760","ML",,"76.04","76.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE 10 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-0904-05","NDC",,,"facility","inpatient","9.972074","ML",,"26.55","26.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIAZEPAM 1 MG/ML PO SOLN","81000000","CDM","0250","RC","0121-0905-05","NDC",,,"facility","inpatient","5.107411","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP","81000000","CDM","0250","RC","0121-0910-30","NDC",,,"facility","inpatient","30.514532","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE 10 GM/15ML PO SOLN","81000000","CDM","0250","RC","0121-1154-00","NDC",,,"facility","inpatient","33.209999","ML",,"23.29","23.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-1190-00","NDC",,,"facility","inpatient","36.827868","ML",,"24.79","24.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUAIFENESIN-DM 100-10 MG/5ML PO SYRP","81000000","CDM","0250","RC","0121-1276-00","NDC",,,"facility","inpatient","10.509554","ML",,"1.97","1.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALPROATE SODIUM 250 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-1350-00","NDC",,,"facility","inpatient","11.008403","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUAIFENESIN 100 MG/5ML PO LIQD","81000000","CDM","0250","RC","0121-1488-00","NDC",,,"facility","inpatient","10.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-1550-00","NDC",,,"facility","inpatient","10.158730","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-1576-10","NDC",,,"facility","inpatient","10.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUAIFENESIN 100 MG/5ML PO LIQD","81000000","CDM","0250","RC","0121-1744-00","NDC",,,"facility","inpatient","5.268336","ML",,"1.01","1.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-1775-00","NDC",,,"facility","inpatient","5.000000","ML",,"36.06","36.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 160 MG/5ML PO SUSP (PEDIATRIC)","81000000","CDM","0250","RC","0121-1781-00","NDC",,,"facility","inpatient","7.790977","ML",,"3.50","3.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 150 MG/15ML PO LIQD","81000000","CDM","0250","RC","0121-1870-10","NDC",,,"facility","inpatient","10.895522","ML",,"1.24","1.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL 20MG/5ML ORAL LIQD (PEDIATRIC) SH","81000000","CDM","0250","RC","0121-1884-07","NDC",,,"facility","inpatient","7.500000","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN","81000000","CDM","0250","RC","0121-2316-40","NDC",,,"facility","inpatient","16.643805","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE 10 GM/15ML PO SOLN","81000000","CDM","0250","RC","0121-4577-30","NDC",,,"facility","inpatient","37.272727","ML",,"11.54","11.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALPROATE SODIUM 250 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-4675-00","NDC",,,"facility","inpatient","6.829268","ML",,"12.43","12.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOXETINE HCL 20 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-4721-05","NDC",,,"facility","inpatient","5.000000","ML",,"22.57","22.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SENNA 176 MG/5ML PO SYRP","81000000","CDM","0250","RC","0121-4722-15","NDC",,,"facility","inpatient","18.027459","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP","81000000","CDM","0250","RC","0121-4766-05","NDC",,,"facility","inpatient","5.425444","ML",,"1.61","1.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 100 MG/ML PO SOLN","81000000","CDM","0250","RC","0121-4799-40","NDC",,,"facility","inpatient","5.131586","ML",,"43.54","43.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 100 MG/ML PO SOLN","81000000","CDM","0250","RC","0121-4802-05","NDC",,,"facility","inpatient","5.000000","ML",,"31.21","31.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","0121-4827-05","NDC",,,"facility","inpatient","5.227100","ML",,"34.16","34.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE VISCOUS HCL 2 % MT SOLN","81000000","CDM","0250","RC","0121-4950-15","NDC",,,"facility","inpatient","18.749988","ML",,"42.86","42.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 50 MG PO TABS","81000000","CDM","0250","RC","0131-2477-60","NDC",,,"facility","inpatient","1.000000","UN",,"48.54","48.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 100 MG PO TABS","81000000","CDM","0250","RC","0131-2478-35","NDC",,,"facility","inpatient","1.000000","UN",,"88.38","88.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 200 MG PO TABS","81000000","CDM","0250","RC","0131-2480-60","NDC",,,"facility","inpatient","1.000000","UN",,"93","93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCERIN (LAXATIVE) 2 G PR SUPP","81000000","CDM","0250","RC","0132-0079-12","NDC",,,"facility","inpatient","12.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCERIN (LAXATIVE) 1 G PR SUPP","81000000","CDM","0250","RC","0132-0081-12","NDC",,,"facility","inpatient","3.500000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLEET ENEMA 7-19 GM/118ML PR ENEM","81000000","CDM","0250","RC","0132-0201-40","NDC",,,"facility","inpatient","487.666666","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLEET PEDIATRIC 3.5-9.5 GM/59ML PR ENEM","81000000","CDM","0250","RC","0132-0202-20","NDC",,,"facility","inpatient","198.000000","ML",,"6.65","6.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINERAL OIL PR ENEM","81000000","CDM","0250","RC","0132-0301-40","NDC",,,"facility","inpatient","167.322580","ML",,"1.89","1.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIAZEPAM 5 MG PO TABS","81000000","CDM","0250","RC","0140-0005-01","NDC",,,"facility","inpatient","1.000000","UN",,"34.35","34.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIAZEPAM 10 MG PO TABS","81000000","CDM","0250","RC","0140-0006-01","NDC",,,"facility","inpatient","1.000000","UN",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 125 MCG PO TABS","81000000","CDM","0250","RC","0143-1240-01","NDC",,,"facility","inpatient","1.000000","UN",,"13.82","13.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 5 MG PO TABS","81000000","CDM","0250","RC","0143-1769-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE MONONITRATE ER 60 MG PO TB24","81000000","CDM","0250","RC","0143-2260-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 875 MG PO TABS","81000000","CDM","0250","RC","0143-9285-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOMIDATE 2 MG/ML IV SOLN","81000000","CDM","0250","RC","0143-9310-10","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE 100 MG/100ML NS (MINIBAG)","81000000","CDM","0250","RC","0143-9381-10","NDC",,,"facility","inpatient","1.166666","UN",,"176.9","176.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOMIDATE 2 MG/ML IV SOLN","81000000","CDM","0250","RC","0143-9506-10","NDC",,,"facility","inpatient","10.754716","ML",,"73.54","73.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOMIDATE 2 MG/ML IV SOLN","81000000","CDM","0250","RC","0143-9507-10","NDC",,,"facility","inpatient","22.480620","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL 50 MG/ML IJ SOLN","81000000","CDM","0250","RC","0143-9508-10","NDC",,,"facility","inpatient","7.688000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUMAZENIL 0.1 MG/ML IV SOLN - CONSOLIDATED","81000000","CDM","0250","RC","0143-9784-10","NDC",,,"facility","inpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENALAPRILAT 1.25 MG/ML IV INJ","81000000","CDM","0250","RC","0143-9787-10","NDC",,,"facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 750 MG PO TABS","81000000","CDM","0250","RC","0143-9929-50","NDC",,,"facility","inpatient","1.000000","UN",,"31.05","31.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR","81000000","CDM","0250","RC","0143-9982-50","NDC",,,"facility","inpatient","50.000000","ML",,"52.17","52.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","81000000","CDM","0250","RC","0168-0004-80","NDC",,,"facility","inpatient","80.000000","GR",,"54.6","54.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX OINT","81000000","CDM","0250","RC","0168-0006-15","NDC",,,"facility","inpatient","15.000000","GR",,"36.27","36.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX OINT","81000000","CDM","0250","RC","0168-0007-15","NDC",,,"facility","inpatient","15.000000","GR",,"84","84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 0.5 % EX CREA","81000000","CDM","0250","RC","0168-0014-31","NDC",,,"facility","inpatient","28.350000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 1 % EX CREA","81000000","CDM","0250","RC","0168-0015-31","NDC",,,"facility","inpatient","28.350000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT","81000000","CDM","0250","RC","0168-0021-35","NDC",,,"facility","inpatient","14.170000","GM",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX CREA","81000000","CDM","0250","RC","0168-0054-15","NDC",,,"facility","inpatient","15.000000","GR",,"87.53","87.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 2.5 % EX CREA","81000000","CDM","0250","RC","0168-0080-31","NDC",,,"facility","inpatient","30.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOCONAZOLE 2 % EX CREA","81000000","CDM","0250","RC","0168-0099-15","NDC",,,"facility","inpatient","15.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN ZINC 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","0168-0111-09","NDC",,,"facility","inpatient","1.016129","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBETASOL PROPIONATE 0.05 % EX OINT","81000000","CDM","0250","RC","0168-0162-15","NDC",,,"facility","inpatient","75.000000","GR",,"621.78","621.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBETASOL PROPIONATE 0.05 % EX OINT","81000000","CDM","0250","RC","0168-0162-30","NDC",,,"facility","inpatient","150.000000","GR",,"1038.96","1038.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBETASOL PROPIONATE 0.05 % EX CREA","81000000","CDM","0250","RC","0168-0163-15","NDC",,,"facility","inpatient","15.000000","GR",,"512.94","512.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 1 % EX OINT","81000000","CDM","0250","RC","0168-0181-31","NDC",,,"facility","inpatient","28.350000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX OINT","81000000","CDM","0250","RC","0168-0204-37","NDC",,,"facility","inpatient","1","EA",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 35.440000 APPLICATION"
"HYDROCORTISONE 2.5 % EX LOTN","81000000","CDM","0250","RC","0168-0288-02","NDC",,,"facility","inpatient","59.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 0.75 % EX CREA","81000000","CDM","0250","RC","0168-0323-46","NDC",,,"facility","inpatient","45.000000","GR",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCHLOROTHIAZIDE 25 MG PO TABS","81000000","CDM","0250","RC","0172-2083-80","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCHLOROTHIAZIDE 50 MG PO TABS","81000000","CDM","0250","RC","0172-2089-60","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIAZEPAM 5 MG PO TABS","81000000","CDM","0250","RC","0172-3926-60","NDC",,,"facility","inpatient","1.062500","UN",,"37","37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 50 MG PO TABS","81000000","CDM","0250","RC","0172-5410-46","NDC",,,"facility","inpatient","1.000000","UN",,"30.64","30.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 100 MG PO TABS","81000000","CDM","0250","RC","0172-5411-46","NDC",,,"facility","inpatient","1.000000","UN",,"42.90","42.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 20 MG PO TABS","81000000","CDM","0250","RC","0172-5728-70","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SALMETEROL XINAFOATE 50 MCG/ACT IN AEPB","81000000","CDM","0250","RC","0173-0521-00","NDC",,,"facility","inpatient","60.000000","UN",,"1524.42","1524.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATOVAQUONE 750 MG/5ML PO SUSP","81000000","CDM","0250","RC","0173-0547-00","NDC",,,"facility","inpatient","5.455580","ML",,"119.36","119.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE 25 MG PO TABS","81000000","CDM","0250","RC","0173-0633-02","NDC",,,"facility","inpatient","1.000000","UN",,"36.75","36.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE 100 MG PO TABS","81000000","CDM","0250","RC","0173-0642-55","NDC",,,"facility","inpatient","1.000000","UN",,"46.08","46.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","81000000","CDM","0250","RC","0173-0682-20","NDC",,,"facility","inpatient","54.000000","GR",,"342.09","342.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","81000000","CDM","0250","RC","0173-0682-24","NDC",,,"facility","inpatient","8.000000","GR","PN","136.32","136.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","81000000","CDM","0250","RC","0173-0682-24","NDC",,,"facility","inpatient","9.900751","GR",,"135.78","135.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DUTASTERIDE 0.5 MG PO CAPS","81000000","CDM","0250","RC","0173-0712-15","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE PROPIONATE HFA 44 MCG/ACT IN AERO","81000000","CDM","0250","RC","0173-0718-20","NDC",,,"facility","inpatient","10.600000","GR",,"981.82","981.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE PROPIONATE HFA 110 MCG/ACT IN AERO","81000000","CDM","0250","RC","0173-0719-20","NDC",,,"facility","inpatient","12.000000","GR",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUMATRIPTAN SUCCINATE 50 MG PO TABS","81000000","CDM","0250","RC","0173-0736-01","NDC",,,"facility","inpatient","1.000000","UN",,"272.59","272.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE FUROATE 100 MCG/ACT IN AEPB","81000000","CDM","0250","RC","0173-0874-14","NDC",,,"facility","inpatient","14.000000","UN",,"466.98","466.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE FUROATE 200 MCG/ACT IN AEPB","81000000","CDM","0250","RC","0173-0876-14","NDC",,,"facility","inpatient","14.000000","UN",,"625.24","625.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS","81000000","CDM","0250","RC","0173-0884-08","NDC",,,"facility","inpatient","1.000000","UN",,"1.33","1.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE FUROATE 50 MCG/ACT IN AEPB","81000000","CDM","0250","RC","0173-0888-10","NDC",,,"facility","inpatient","0.903333","UN",,"33.36","33.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALACYCLOVIR HCL 500 MG PO TABS","81000000","CDM","0250","RC","0173-0933-08","NDC",,,"facility","inpatient","1.000000","UN",,"61.56","61.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 300 MG PO TABS","81000000","CDM","0250","RC","0185-0118-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS","81000000","CDM","0250","RC","0185-0122-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.32","14.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 1 MG PO TABS","81000000","CDM","0250","RC","0185-0129-01","NDC",,,"facility","inpatient","1.000000","UN",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 2 MG PO TABS","81000000","CDM","0250","RC","0185-0130-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.03","14.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CITALOPRAM HYDROBROMIDE 10 MG PO TABS","81000000","CDM","0250","RC","0185-0371-01","NDC",,,"facility","inpatient","5.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 2.5 MG PO TABS","81000000","CDM","0250","RC","0185-0602-01","NDC",,,"facility","inpatient","1.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 10 MG PO TABS","81000000","CDM","0250","RC","0185-0610-01","NDC",,,"facility","inpatient","1.076923","UN",,"13.33","13.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 20 MG PO TABS","81000000","CDM","0250","RC","0185-0620-01","NDC",,,"facility","inpatient","2.142857","UN",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 40 MG PO TABS","81000000","CDM","0250","RC","0185-0640-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLESTYRAMINE LIGHT 4 G PO PACK","81000000","CDM","0250","RC","0185-0939-98","NDC",,,"facility","inpatient","1.000000","UN",,"18.43","18.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO","81000000","CDM","0250","RC","0186-0370-20","NDC",,,"facility","inpatient","132.600000","GR",,"1405.67","1405.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO","81000000","CDM","0250","RC","0186-0370-28","NDC",,,"facility","inpatient","7.493449","GR",,"871.26","871.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO","81000000","CDM","0250","RC","0186-0372-28","NDC",,,"facility","inpatient","8.000613","GR",,"735.69","735.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TICAGRELOR 90 MG PO TABS","81000000","CDM","0250","RC","0186-0777-39","NDC",,,"facility","inpatient","1.115983","UN",,"48.17","48.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESOMEPRAZOLE MAGNESIUM 5MG PO PACK (PEDIATRIC)","81000000","CDM","0250","RC","0186-4050-01","NDC",,,"facility","inpatient","1.020018","UN",,"40.38","40.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24","81000000","CDM","0250","RC","0187-0797-42","NDC",,,"facility","inpatient","5.000000","UN",,"174.96","174.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 5 % EX CREA","81000000","CDM","0250","RC","0187-0994-45","NDC",,,"facility","inpatient","5.000000","GR",,"960","960",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHYTONADIONE 5 MG PO TABS","81000000","CDM","0250","RC","0187-1704-05","NDC",,,"facility","inpatient","1.000000","UN",,"1.33","1.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOSTIGMINE BROMIDE 60 MG PO TABS","81000000","CDM","0250","RC","0187-3010-30","NDC",,,"facility","inpatient","1.000000","UN",,"96.21","96.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 1 G PO TABS","81000000","CDM","0250","RC","0223-1760-01","NDC",,,"facility","inpatient","1.000000","UN",,"1.33","1.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PSYLLIUM VARIABLE DOSE POWDER SF SH","81000000","CDM","0250","RC","0224180100","NDC",,,"facility","inpatient","1.000000","UN",,"1.67","1.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AYR SALINE NASAL NA GEL","81000000","CDM","0250","RC","0225-0525-47","NDC",,,"facility","inpatient","14.100000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 0.25 MG PO TABS","81000000","CDM","0250","RC","0228-2027-10","NDC",,,"facility","inpatient","1.000000","UN",,"22.22","22.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 0.5 MG PO TABS","81000000","CDM","0250","RC","0228-2029-10","NDC",,,"facility","inpatient","1.214285","UN",,"26.11","26.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE HCL 0.1 MG PO TABS","81000000","CDM","0250","RC","0228-2127-10","NDC",,,"facility","inpatient","1.048192","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE HCL 0.2 MG PO TABS","81000000","CDM","0250","RC","0228-2128-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE HCL 0.3 MG PO TABS","81000000","CDM","0250","RC","0228-2129-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE 10 MG PO CAPS","81000000","CDM","0250","RC","0228-2497-10","NDC",,,"facility","inpatient","1.301886","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE 20 MG PO CAPS","81000000","CDM","0250","RC","0228-2530-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA 10-100 MG PO TABS","81000000","CDM","0250","RC","0228-2538-10","NDC",,,"facility","inpatient","5.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 800 MG PO TABS","81000000","CDM","0250","RC","0228-2637-11","NDC",,,"facility","inpatient","1.000000","UN",,"16.67","16.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL 8 MG SL SUBL","81000000","CDM","0250","RC","0228-3153-03","NDC",,,"facility","inpatient","1.727272","UN",,"33.03","33.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL 2 MG SL SUBL","81000000","CDM","0250","RC","0228-3156-03","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORHEXIDINE GLUCONATE 4 % EX LIQD","81000000","CDM","0250","RC","0234-0575-17","NDC",,,"facility","inpatient","15.571428","ML",,"1.93","1.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SOTALOL HCL 80 MG PO TABS","81000000","CDM","0250","RC","0245-0012-01","NDC",,,"facility","inpatient","1.000000","UN",,"13.31","13.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLESTYRAMINE LIGHT 4 G PO PACK","81000000","CDM","0250","RC","0245-0036-42","NDC",,,"facility","inpatient","1.098654","UN",,"28.11","28.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE CR 10 MEQ PO TBCR SH","81000000","CDM","0250","RC","0245-0041-01","NDC",,,"facility","inpatient","2.230769","UN",,"6.82","6.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 400 MG PO TABS","81000000","CDM","0250","RC","0245-0145-01","NDC",,,"facility","inpatient","1.000000","UN",,"63.39","63.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 200 MG PO TABS","81000000","CDM","0250","RC","0245-0147-01","NDC",,,"facility","inpatient","1.009163","UN",,"36.37","36.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0245-0212-01","NDC",,,"facility","inpatient","1.062695","UN",,"23.58","23.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0245-0212-11","NDC",,,"facility","inpatient","1.000000","UN",,"18.59","18.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 400 MG PO TABS","81000000","CDM","0250","RC","0245-1645-01","NDC",,,"facility","inpatient","1.096385","UN",,"60.03","60.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE CR 10 MEQ PO TBCR SH","81000000","CDM","0250","RC","0245-5316-89","NDC",,,"facility","inpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE CR 10 MEQ PO TBCR SH","81000000","CDM","0250","RC","0245-5317-89","NDC",,,"facility","inpatient","1.144237","UN",,"9.03","9.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE CR 20 MEQ PO TBCR SH","81000000","CDM","0250","RC","0245-5319-89","NDC",,,"facility","inpatient","1.000000","UN","PN","10.5","10.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"POTASSIUM CHLORIDE CR 20 MEQ PO TBCR SH","81000000","CDM","0250","RC","0245-5319-89","NDC",,,"facility","inpatient","1.117063","UN",,"9.55","9.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETIC ACID 0.25 % IR SOLN","81000000","CDM","0250","RC","0264-2304-00","NDC",,,"facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SURGILUBE EX GEL","81000000","CDM","0250","RC","0281-0205-02","NDC",,,"facility","inpatient","77.318181","GM",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 2 % TD OINT","81000000","CDM","0250","RC","0281-0326-08","NDC",,,"facility","inpatient","1.321839","GR",,"14.76","14.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE 20 % MT AERO","81000000","CDM","0250","RC","0283-0679-02","NDC",,,"facility","inpatient","65.245612","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETAPHIL MOISTURIZING EX LOTN","81000000","CDM","0250","RC","0299-0241-32","NDC",,,"facility","inpatient","286.894736","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUETIAPINE FUMARATE 200 MG PO TABS","81000000","CDM","0250","RC","0310-0272-10","NDC",,,"facility","inpatient","1.000000","UN",,"49.05","49.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUETIAPINE FUMARATE 25 MG PO TABS","81000000","CDM","0250","RC","0310-0275-10","NDC",,,"facility","inpatient","2.032258","UN",,"24.46","24.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROSUVASTATIN CALCIUM 20 MG PO TABS","81000000","CDM","0250","RC","0310-0752-90","NDC",,,"facility","inpatient","1.000000","UN",,"44.25","44.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM ZIRCONIUM CYCLOSILICATE 5 G PO PACK","81000000","CDM","0250","RC","0310-1105-30","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK","81000000","CDM","0250","RC","0310-1110-30","NDC",,,"facility","inpatient","1.094476","UN",,"99.92","99.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK","81000000","CDM","0250","RC","0310-1110-39","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXEGOL OXALATE 12.5 MG PO TABS","81000000","CDM","0250","RC","0310-1969-30","NDC",,,"facility","inpatient","1.000000","UN",,"56.86","56.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXEGOL OXALATE 25 MG PO TABS","81000000","CDM","0250","RC","0310-1970-30","NDC",,,"facility","inpatient","1.000000","UN",,"56.86","56.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPAGLIFLOZIN PROPANEDIOL 5 MG PO TABS","81000000","CDM","0250","RC","0310-6205-30","NDC",,,"facility","inpatient","1.057142","UN",,"92.48","92.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPAGLIFLOZIN PROPANEDIOL 10 MG PO TABS","81000000","CDM","0250","RC","0310-6210-30","NDC",,,"facility","inpatient","1.000000","UN",,"84.05","84.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPAGLIFLOZIN PROPANEDIOL 10 MG PO TABS","81000000","CDM","0250","RC","0310-6210-39","NDC",,,"facility","inpatient","1.048698","UN",,"90.17","90.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO","81000000","CDM","0250","RC","0310-7370-20","NDC",,,"facility","inpatient","10.200000","GR",,"1208.88","1208.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO","81000000","CDM","0250","RC","0310-7372-20","NDC",,,"facility","inpatient","10.199964","GR",,"516.49","516.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICONAZOLE NITRATE 2 % EX POWD","81000000","CDM","0250","RC","0316-0225-15","NDC",,,"facility","inpatient","43.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN","81000000","CDM","0250","RC","0316-0229-75","NDC",,,"facility","inpatient","1205.142857","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMOXINE-MENTHOL 1-0.5 % EX LOTN","81000000","CDM","0250","RC","0316-0234-75","NDC",,,"facility","inpatient","222.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR","81000000","CDM","0250","RC","0338-0322-01","NDC",,,"facility","inpatient","1.000000","UN",,"412.8","412.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR","81000000","CDM","0250","RC","0338-0324-01","NDC",,,"facility","inpatient","1.000000","UN",,"412.8","412.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MANNITOL 20 % IV SOLN","81000000","CDM","0250","RC","0338-0357-02","NDC",,,"facility","inpatient","250.000000","ML",,"332.03","332.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MANNITOL 20% IVPB INTERMITTENT SH","81000000","CDM","0250","RC","0338-0357-03","NDC",,,"facility","inpatient","597.873960","ML",,"192.74","192.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN 2MG/ML NS IV SYRINGE (PEDIATRIC) SH","81000000","CDM","0250","RC","0338-0511-41","NDC",,,"facility","inpatient","50.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL","81000000","CDM","0250","RC","0338-0519-09","NDC",,,"facility","inpatient","275.641025","ML",,"367.25","367.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAT EMULSION 20% IV (NEONATAL)","81000000","CDM","0250","RC","0338-0519-58","NDC",,,"facility","inpatient","100.000000","ML",,"77.73","77.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETIC ACID 0.25 % IR SOLN","81000000","CDM","0250","RC","0338-0656-04","NDC",,,"facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 100MCG/ML INJ","81000000","CDM","0250","RC","0338-1047-02","NDC",,,"facility","inpatient","375.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROGEN PEROXIDE 3 % EX SOLN","81000000","CDM","0250","RC","0363-0871-34","NDC",,,"facility","inpatient","237.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICOTINE POLACRILEX 2 MG MT GUM","81000000","CDM","0250","RC","0363-4122-50","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR","81000000","CDM","0250","RC","0378-0088-01","NDC",,,"facility","inpatient","5.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROBENECID 500 MG PO TABS","81000000","CDM","0250","RC","0378-0156-01","NDC",,,"facility","inpatient","1.500000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORTHALIDONE 25 MG PO TABS","81000000","CDM","0250","RC","0378-0222-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS","81000000","CDM","0250","RC","0378-0415-01","NDC",,,"facility","inpatient","1.000000","UN",,"26.67","26.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 100 MG PO TABS","81000000","CDM","0250","RC","0378-0437-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.83","7.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE ER OSMOTIC RELEASE 90 MG PO TB24","81000000","CDM","0250","RC","0378-0494-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCHLOROTHIAZIDE 12.5 MG PO CAPS","81000000","CDM","0250","RC","0378-0810-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE 0.1 MG/24HR TD PTWK","81000000","CDM","0250","RC","0378-0871-99","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE 0.2 MG/24HR TD PTWK","81000000","CDM","0250","RC","0378-0872-99","NDC",,,"facility","inpatient","2.333333","UN",,"167.3","167.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE 0.3 MG/24HR TD PTWK","81000000","CDM","0250","RC","0378-0873-99","NDC",,,"facility","inpatient","1.571428","UN",,"232.08","232.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NADOLOL 40 MG PO TABS","81000000","CDM","0250","RC","0378-1171-01","NDC",,,"facility","inpatient","1.000000","UN",,"21.83","21.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 112 MCG PO TABS","81000000","CDM","0250","RC","0378-1811-77","NDC",,,"facility","inpatient","9.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 2.5 MG PO TABS","81000000","CDM","0250","RC","0378-1901-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0378-1903-01","NDC",,,"facility","inpatient","1.064000","UN",,"25.29","25.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BROMOCRIPTINE MESYLATE 2.5 MG PO TABS","81000000","CDM","0250","RC","0378-2042-01","NDC",,,"facility","inpatient","1.000000","UN",,"34.47","34.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 150 MG PO TABS","81000000","CDM","0250","RC","0378-2695-01","NDC",,,"facility","inpatient","1.000000","UN",,"20.96","20.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESTRADIOL 0.05 MG/24HR TD PTWK","81000000","CDM","0250","RC","0378-3350-99","NDC",,,"facility","inpatient","1.000000","UN",,"92.83","92.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESTRADIOL 0.075 MG/24HR TD PTWK","81000000","CDM","0250","RC","0378-3351-99","NDC",,,"facility","inpatient","1.000000","UN",,"92.83","92.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIRTAZAPINE 15 MG PO TABS","81000000","CDM","0250","RC","0378-3515-93","NDC",,,"facility","inpatient","1.105263","UN",,"14.71","14.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEVIRAPINE ER 400 MG PO TB24","81000000","CDM","0250","RC","0378-4890-93","NDC",,,"facility","inpatient","1.000000","UN",,"94.19","94.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXEPIN HCL 75 MG PO CAPS","81000000","CDM","0250","RC","0378-5375-01","NDC",,,"facility","inpatient","1.000000","UN",,"9.96","9.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 1 MG PO TABS","81000000","CDM","0250","RC","0378-5501-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 2 MG PO TABS","81000000","CDM","0250","RC","0378-5502-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 0.5 MG PO TABS","81000000","CDM","0250","RC","0378-5550-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.26","10.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CITALOPRAM HYDROBROMIDE 20 MG PO TABS","81000000","CDM","0250","RC","0378-6232-01","NDC",,,"facility","inpatient","1.290909","UN",,"14.91","14.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANSOPRAZOLE 30 MG PO TBDD","81000000","CDM","0250","RC","0378-6982-88","NDC",,,"facility","inpatient","1.000000","UN",,"51.83","51.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 3% IN NEBU","81000000","CDM","0250","RC","0378-6997-89","NDC",,,"facility","inpatient","15.908566","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 10 % IN NEBU","81000000","CDM","0250","RC","0378-6998-89","NDC",,,"facility","inpatient","15.858049","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 3 MG PO CPEP","81000000","CDM","0250","RC","0378-7155-01","NDC",,,"facility","inpatient","1.000000","UN",,"75.38","75.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO","81000000","CDM","0250","RC","0378-7502-32","NDC",,,"facility","inpatient","10.300000","GR",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 8 MG PO TBDP","81000000","CDM","0250","RC","0378-7734-93","NDC",,,"facility","inpatient","2.230769","UN",,"111.40","111.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.1 MG/HR TD PT24","81000000","CDM","0250","RC","0378-9102-93","NDC",,,"facility","inpatient","30.003000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG/HR TD PT24","81000000","CDM","0250","RC","0378-9112-93","NDC",,,"facility","inpatient","1.571428","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 25 MCG/HR TD PT72","81000000","CDM","0250","RC","0378-9121-98","NDC",,,"facility","inpatient","1.000000","UN",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 100 MCG/HR TD PT72","81000000","CDM","0250","RC","0378-9124-98","NDC",,,"facility","inpatient","2.200000","UN",,"160.08","160.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCERIN LIQD","81000000","CDM","0250","RC","0395-1031-16","NDC",,,"facility","inpatient","488.955435","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","0406-0123-23","NDC",,,"facility","inpatient","1.000000","UN","PN","40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","0406-0123-23","NDC",,,"facility","inpatient","1.095190","UN",,"39.41","39.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","0406-0123-62","NDC",,,"facility","inpatient","1.173913","UN",,"34.88","34.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS","81000000","CDM","0250","RC","0406-0124-23","NDC",,,"facility","inpatient","1.030226","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS","81000000","CDM","0250","RC","0406-0124-62","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS","81000000","CDM","0250","RC","0406-0125-23","NDC",,,"facility","inpatient","1.070252","UN",,"38.17","38.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS","81000000","CDM","0250","RC","0406-0125-62","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN-CODEINE 300-15 MG PO TABS","81000000","CDM","0250","RC","0406-0483-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN-CODEINE 300-30 MG PO TABS","81000000","CDM","0250","RC","0406-0484-23","NDC",,,"facility","inpatient","1.500000","UN",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN-CODEINE 300-60 MG PO TABS","81000000","CDM","0250","RC","0406-0485-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","0406-0512-23","NDC",,,"facility","inpatient","1.141308","UN",,"38.17","38.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","0406-0512-62","NDC",,,"facility","inpatient","1.480000","UN",,"28.27","28.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS","81000000","CDM","0250","RC","0406-0523-23","NDC",,,"facility","inpatient","1.164383","UN",,"39.69","39.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0406-0552-23","NDC",,,"facility","inpatient","1.061236","UN",,"26.12","26.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0406-0552-62","NDC",,,"facility","inpatient","1.240270","UN",,"31.05","31.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALTREXONE HCL 50 MG PO TABS","81000000","CDM","0250","RC","0406-1170-03","NDC",,,"facility","inpatient","1.000000","UN",,"22.23","22.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS","81000000","CDM","0250","RC","0406-1236-01","NDC",,,"facility","inpatient","1.076677","UN",,"31.44","31.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG PO TABS","81000000","CDM","0250","RC","0406-3243-01","NDC",,,"facility","inpatient","1.061626","UN",,"21.89","21.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 4 MG PO TABS","81000000","CDM","0250","RC","0406-3244-01","NDC",,,"facility","inpatient","1.035164","UN",,"33.79","33.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 8 MG PO TABS","81000000","CDM","0250","RC","0406-3249-01","NDC",,,"facility","inpatient","3.666666","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE ER 15 MG PO TBCR","81000000","CDM","0250","RC","0406-8315-23","NDC",,,"facility","inpatient","1.158454","UN",,"30.87","30.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE ER 15 MG PO TBCR","81000000","CDM","0250","RC","0406-8315-62","NDC",,,"facility","inpatient","1.000000","UN",,"28.87","28.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE ER 60 MG PO TBCR","81000000","CDM","0250","RC","0406-8380-23","NDC",,,"facility","inpatient","1.056338","UN",,"39.48","39.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE ER 100 MG PO TBCR","81000000","CDM","0250","RC","0406-8390-23","NDC",,,"facility","inpatient","1.000000","UN",,"49.63","49.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 30 MG PO TABS","81000000","CDM","0250","RC","0406-8530-23","NDC",,,"facility","inpatient","1.048681","UN",,"34.47","34.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 100 MCG/HR TD PT72","81000000","CDM","0250","RC","0406-9100-76","NDC",,,"facility","inpatient","1.000000","UN",,"160.08","160.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TEMAZEPAM 7.5 MG PO CAPS","81000000","CDM","0250","RC","0406-9915-01","NDC",,,"facility","inpatient","1.000000","UN",,"106.21","106.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TEMAZEPAM 15 MG PO CAPS","81000000","CDM","0250","RC","0406-9961-01","NDC",,,"facility","inpatient","1.045454","UN",,"24.71","24.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL 100MCG/ML IN NS (CUSTOM) NARRATOR","81000000","CDM","0250","RC","0409-1144-01","NDC",,,"facility","inpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL 2.5 MG/ML IV SOLN","81000000","CDM","0250","RC","0409-1144-05","NDC",,,"facility","inpatient","2.274713","ML",,"227.54","227.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL 2.5 MG/ML IV SOLN","81000000","CDM","0250","RC","0409-1144-65","NDC",,,"facility","inpatient","2.000000","ML",,"229.19","229.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN","81000000","CDM","0250","RC","0409-1209-01","NDC",,,"facility","inpatient","5.104294","ML",,"69.78","69.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN","81000000","CDM","0250","RC","0409-1596-01","NDC",,,"facility","inpatient","107.765314","ML",,"389.57","389.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VECURONIUM BROMIDE 10 MG IV SOLR","81000000","CDM","0250","RC","0409-1632-01","NDC",,,"facility","inpatient","1.231736","UN",,"70.78","70.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN","81000000","CDM","0250","RC","0409-1638-02","NDC",,,"facility","inpatient","2.596012","ML",,"69.94","69.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN","81000000","CDM","0250","RC","0409-1660-10","NDC",,,"facility","inpatient","100.000000","ML",,"390","390",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN","81000000","CDM","0250","RC","0409-1660-35","NDC",,,"facility","inpatient","104.700854","ML",,"390","390",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 200 MCG/50ML IV SOLN","81000000","CDM","0250","RC","0409-1660-50","NDC",,,"facility","inpatient","60.526315","ML",,"218.4","218.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN","81000000","CDM","0250","RC","0409-1746-30","NDC",,,"facility","inpatient","40.448053","ML",,"86.29","86.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","81000000","CDM","0250","RC","0409-1749-29","NDC",,,"facility","inpatient","42.622894","ML",,"74.12","74.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL TARTRATE 5 MG/5ML IV SOLN","81000000","CDM","0250","RC","0409-1778-05","NDC",,,"facility","inpatient","5.641197","ML",,"70.90","70.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL 100 MG/ML IJ SOLN","81000000","CDM","0250","RC","0409-2051-05","NDC",,,"facility","inpatient","5.129032","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN","81000000","CDM","0250","RC","0409-3177-01","NDC",,,"facility","inpatient","86.363636","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","0409-3178-01","NDC",,,"facility","inpatient","20.532150","ML","PN","74.51","74.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","0409-3178-01","NDC",,,"facility","inpatient","25.714285","ML",,"70.35","70.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","0409-3178-02","NDC",,,"facility","inpatient","30.000000","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","0409-3178-02","NDC",,,"facility","inpatient","90.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN PF","81000000","CDM","0250","RC","0409-3181-01","NDC",,,"facility","inpatient","29.999658","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","0409-3182-01","NDC",,,"facility","inpatient","23.888888","ML",,"70.70","70.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 2%-1:200000 IJ SOLN PF","81000000","CDM","0250","RC","0409-3183-01","NDC",,,"facility","inpatient","20.000000","ML",,"69.70","69.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % ORAL SOLN CUSTOM CREATE","81000000","CDM","0250","RC","0409-3308-03","NDC",,,"facility","inpatient","30.000000","ML",,"50.49","50.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 50MG/ML PO SOLN *COMPOUNDED*","81000000","CDM","0250","RC","0409-4332-49","NDC",,,"facility","inpatient","10.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","0409-4888-10","NDC",,,"facility","inpatient","10.000000","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","0409-4888-10","NDC",,,"facility","inpatient","10.508906","ML",,"70.66","70.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","0409-4888-20","NDC",,,"facility","inpatient","20.000000","ML","PN","42.19","42.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","0409-4888-20","NDC",,,"facility","inpatient","21.167979","ML",,"72.05","72.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","0409-4888-50","NDC",,,"facility","inpatient","58.073184","ML",,"74.41","74.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","0409-4900-24","NDC",,,"facility","inpatient","10.000000","ML",,"184.15","184.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","0409-4900-34","NDC",,,"facility","inpatient","22.800000","ML",,"97.92","97.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE HCL 0.1 MG/ML IJ SOLN (IO)","81000000","CDM","0250","RC","0409-4921-34","NDC",,,"facility","inpatient","15.714285","ML",,"61.73","61.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CHLORIDE 10 % IV SOLN","81000000","CDM","0250","RC","0409-4928-34","NDC",,,"facility","inpatient","10.370746","ML",,"115.15","115.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 4.2 % IV SOLN","81000000","CDM","0250","RC","0409-5534-34","NDC",,,"facility","inpatient","14.651884","ML",,"63.68","63.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 4.2 % IV SOLN","81000000","CDM","0250","RC","0409-5555-01","NDC",,,"facility","inpatient","5.000000","ML",,"55.05","55.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 4.2 % IV SOLN","81000000","CDM","0250","RC","0409-5555-12","NDC",,,"facility","inpatient","5.000000","ML",,"57.35","57.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETIC ACID 0.25 % IR SOLN","81000000","CDM","0250","RC","0409-6143-22","NDC",,,"facility","inpatient","250.000000","ML",,"54.17","54.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","0409-6625-02","NDC",,,"facility","inpatient","51.883077","ML",,"77.65","77.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","0409-6625-14","NDC",,,"facility","inpatient","61.152416","ML",,"76.19","76.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","0409-6625-22","NDC",,,"facility","inpatient","52.595101","ML",,"77.06","77.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","0409-6637-24","NDC",,,"facility","inpatient","53.333333","ML",,"144.02","144.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","0409-6637-34","NDC",,,"facility","inpatient","87.200651","ML",,"88","88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOMIDATE 2 MG/ML IV SOLN","81000000","CDM","0250","RC","0409-6695-01","NDC",,,"facility","inpatient","10.863136","ML",,"74.20","74.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOMIDATE 2 MG/ML IV SOLN","81000000","CDM","0250","RC","0409-6695-02","NDC",,,"facility","inpatient","20.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","0409-7295-01","NDC",,,"facility","inpatient","15.745338","ML",,"77.32","77.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM ACETATE 2 MEQ/ML IV SOLN","81000000","CDM","0250","RC","0409-7299-73","NDC",,,"facility","inpatient","22.732710","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM PHOSPHATES 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","0409-7391-72","NDC",,,"facility","inpatient","15.000041","ML",,"81.47","81.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM ACETATE 2 MEQ/ML IV SOLN","81000000","CDM","0250","RC","0409-8183-01","NDC",,,"facility","inpatient","39.405700","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN","81000000","CDM","0250","RC","0409-9042-01","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN","81000000","CDM","0250","RC","0409-9042-17","NDC",,,"facility","inpatient","34.864864","ML",,"57.70","57.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","81000000","CDM","0250","RC","0409-9045-01","NDC",,,"facility","inpatient","10.000000","ML",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SACCHAROMYCES BOULARDII 250 MG PO CAPS","81000000","CDM","0250","RC","04142-00024","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AEROCHAMBER Z-STAT PLUS/MEDIUM MISC","81000000","CDM","0250","RC","04351-78710","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAKINS (1/4 STRENGTH) 0.125 % EX SOLN CUSTOM","81000000","CDM","0250","RC","0436-0672-16","NDC",,,"facility","inpatient","518.637795","ML",,"1.84","1.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAKINS (1/2 STRENGTH) 0.25 % EX SOLN","81000000","CDM","0250","RC","0436-0936-16","NDC",,,"facility","inpatient","473.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAKINS (FULL STRENGTH) 0.5 % EX SOLN","81000000","CDM","0250","RC","0436-0946-16","NDC",,,"facility","inpatient","473.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAPROXEN 500 MG PO TABS","81000000","CDM","0250","RC","0440-1852-60","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 200 MG PO CAPS","81000000","CDM","0250","RC","0440-6030-01","NDC",,,"facility","inpatient","1.000000","UN",,"8.33","8.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CITALOPRAM HYDROBROMIDE 20 MG PO TABS","81000000","CDM","0250","RC","0440-7293-30","NDC",,,"facility","inpatient","1.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERBINAFINE HCL 250 MG PO TABS","81000000","CDM","0250","RC","0440-8489-40","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THYROID 15 MG PO TABS","81000000","CDM","0250","RC","0456-0457-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THYROID 60 MG PO TABS","81000000","CDM","0250","RC","0456-0459-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINACLOTIDE 145 MCG PO CAPS","81000000","CDM","0250","RC","0456-1201-30","NDC",,,"facility","inpatient","1.000000","UN",,"85.94","85.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINACLOTIDE 290 MCG PO CAPS","81000000","CDM","0250","RC","0456-1202-30","NDC",,,"facility","inpatient","1.070942","UN",,"85.37","85.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINACLOTIDE 72 MCG PO CAPS","81000000","CDM","0250","RC","0456-1203-30","NDC",,,"facility","inpatient","1.000000","UN",,"84.48","84.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 10 MG PO TABS","81000000","CDM","0250","RC","0456-2010-01","NDC",,,"facility","inpatient","1.363636","UN",,"58.27","58.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 20 MG PO TABS","81000000","CDM","0250","RC","0456-2020-01","NDC",,,"facility","inpatient","1.000000","UN",,"73.35","73.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEMANTINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0456-3205-60","NDC",,,"facility","inpatient","1.000000","UN",,"48.92","48.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOSFOMYCIN TROMETHAMINE 3 G PO PACK","81000000","CDM","0250","RC","0456-4300-01","NDC",,,"facility","inpatient","1.000000","UN",,"328.56","328.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISAVUCONAZONIUM SULFATE 186 MG PO CAPS","81000000","CDM","0250","RC","0469-0520-02","NDC",,,"facility","inpatient","1.000000","UN",,"404.56","404.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISAVUCONAZONIUM SULFATE 186 MG PO CAPS","81000000","CDM","0250","RC","0469-0520-14","NDC",,,"facility","inpatient","1.000000","UN",,"363.48","363.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIRABEGRON ER 25 MG PO TB24","81000000","CDM","0250","RC","0469-2601-30","NDC",,,"facility","inpatient","1.000000","UN",,"53.63","53.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERMETHRIN 5 % EX CREA","81000000","CDM","0250","RC","0472-0242-60","NDC",,,"facility","inpatient","60.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN ZINC 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","0472-1105-34","NDC",,,"facility","inpatient","17.043478","GM",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICONAZOLE NITRATE 100 MG VA SUPP","81000000","CDM","0250","RC","0472-1736-07","NDC",,,"facility","inpatient","1.000000","UN",,"1","1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESALAMINE 1000 MG PR SUPP","81000000","CDM","0250","RC","0472-1915-01","NDC",,,"facility","inpatient","5.000000","UN",,"132.44","132.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 88 MCG PO TABS","81000000","CDM","0250","RC","0480-8693-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"K PHOS MONO-SOD PHOS DI & MONO 155-852-130 MG PO TABS","81000000","CDM","0250","RC","0486-1125-01","NDC",,,"facility","inpatient","1.008316","UN",,"10.34","10.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RACEPINEPHRINE HCL 2.25 % IN NEBU","81000000","CDM","0250","RC","0487-5901-99","NDC",,,"facility","inpatient","1.042105","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 3% IN NEBU","81000000","CDM","0250","RC","0487-9003-30","NDC",,,"facility","inpatient","5.341935","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 3% IN NEBU","81000000","CDM","0250","RC","0487-9003-60","NDC",,,"facility","inpatient","4.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 0.9% IN NEBU","81000000","CDM","0250","RC","0487-9301-03","NDC",,,"facility","inpatient","3.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 4 % EX CREA","81000000","CDM","0250","RC","0496-0882-06","NDC",,,"facility","inpatient","5.000000","GR","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE 4 % EX CREA","81000000","CDM","0250","RC","0496-0882-06","NDC",,,"facility","inpatient","5.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 4 % EX CREA","81000000","CDM","0250","RC","0496-0882-15","NDC",,,"facility","inpatient","75.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN","81000000","CDM","0250","RC","0517-0374-05","NDC",,,"facility","inpatient","10.000000","ML",,"1500.99","1500.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN","81000000","CDM","0250","RC","0517-0375-05","NDC",,,"facility","inpatient","5.000000","ML",,"963.77","963.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 100MG/ML SOLN FOR HEMOPTYSIS SH (PEDIATRIC)(NEBULIZATION USE)","81000000","CDM","0250","RC","0517-0960-01","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","0517-2102-01","NDC",,,"facility","inpatient","15.000032","ML",,"163.49","163.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","0517-2102-25","NDC",,,"facility","inpatient","15.000037","ML",,"134.26","134.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CHLORIDE 10 % IV SOLN","81000000","CDM","0250","RC","0517-2710-25","NDC",,,"facility","inpatient","11.509301","ML",,"146.64","146.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CHLORIDE 10 % IV SOLN","81000000","CDM","0250","RC","0517-6710-01","NDC",,,"facility","inpatient","10.000000","ML",,"157.52","157.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CHLORIDE 10 % IV SOLN","81000000","CDM","0250","RC","0517-6710-10","NDC",,,"facility","inpatient","10.000000","ML",,"157.69","157.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % ORAL SOLN CUSTOM CREATE","81000000","CDM","0250","RC","0517-7604-01","NDC",,,"facility","inpatient","4.000000","ML",,"61.52","61.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERBUTALINE SULFATE 5 MG PO TABS","81000000","CDM","0250","RC","0527-1311-01","NDC",,,"facility","inpatient","1.000000","UN",,"36.55","36.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 88 MCG PO TABS","81000000","CDM","0250","RC","0527-1344-01","NDC",,,"facility","inpatient","1.000000","UN",,"13.12","13.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLARITHROMYCIN 500 MG PO TABS","81000000","CDM","0250","RC","0527-1932-06","NDC",,,"facility","inpatient","2.333333","UN",,"33.08","33.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 25 MG/ML PO SOLN","81000000","CDM","0250","RC","0527-1948-66","NDC",,,"facility","inpatient","100.000000","ML",,"157.82","157.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 25 MG/ML PO SOLN","81000000","CDM","0250","RC","0527-1948-68","NDC",,,"facility","inpatient","200.000000","ML",,"321","321",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 25 MG/ML PO SOLN","81000000","CDM","0250","RC","0527-1948-70","NDC",,,"facility","inpatient","479.974570","ML",,"143.96","143.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FEBUXOSTAT 40 MG PO TABS","81000000","CDM","0250","RC","0527-2244-32","NDC",,,"facility","inpatient","1.216216","UN",,"52.8","52.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 25 MG PO TB24","81000000","CDM","0250","RC","0527-2600-37","NDC",,,"facility","inpatient","1.253968","UN",,"14.32","14.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 50 MG PO TB24","81000000","CDM","0250","RC","0527-2601-37","NDC",,,"facility","inpatient","1.188235","UN",,"11.84","11.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUTALBITAL-APAP-CAFFEINE 50-300-40 MG PO CAPS","81000000","CDM","0250","RC","0527-4095-37","NDC",,,"facility","inpatient","1.000000","UN",,"16.15","16.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE (ENULOSE) ENEMA SH","81000000","CDM","0250","RC","0527-5125-70","NDC",,,"facility","inpatient","472.999960","ML",,"88.24","88.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 250 MG PO CAPS","81000000","CDM","0250","RC","0536-1064-01","NDC",,,"facility","inpatient","1.121951","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MUSCLE RUB 10-15 % EX CREA","81000000","CDM","0250","RC","0536-1101-45","NDC",,,"facility","inpatient","92.806122","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CAPSAICIN 0.075 % EX CREA","81000000","CDM","0250","RC","0536-1118-25","NDC",,,"facility","inpatient","57.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % PR SUPP","81000000","CDM","0250","RC","0536-1186-12","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOL 1.4 % MT LIQD","81000000","CDM","0250","RC","0536-1228-58","NDC",,,"facility","inpatient","201.413793","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN ZINC 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","0536-1263-28","NDC",,,"facility","inpatient","28.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN","81000000","CDM","0250","RC","0536-1268-12","NDC",,,"facility","inpatient","225.363636","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 1 % EX CREA","81000000","CDM","0250","RC","0536-1272-22","NDC",,,"facility","inpatient","28.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMETHICONE 40 MG/0.6ML PO SUSP","81000000","CDM","0250","RC","0536-1303-75","NDC",,,"facility","inpatient","30.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLOPATADINE HCL 0.2 % OP SOLN","81000000","CDM","0250","RC","0536-1307-23","NDC",,,"facility","inpatient","2.500000","ML",,"83.95","83.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLOPATADINE HCL 0.1 % OP SOLN","81000000","CDM","0250","RC","0536-1308-40","NDC",,,"facility","inpatient","5.000000","ML",,"91.25","91.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SENNA 176 MG/5ML PO SYRP","81000000","CDM","0250","RC","0536-1335-59","NDC",,,"facility","inpatient","260.400713","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MUSCLE RUB 10-15 % EX CREA","81000000","CDM","0250","RC","0536-1349-57","NDC",,,"facility","inpatient","122.777777","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICOTINE POLACRILEX 2 MG MT GUM","81000000","CDM","0250","RC","0536-1362-23","NDC",,,"facility","inpatient","1.047761","UN",,"1.78","1.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG PO TABS","81000000","CDM","0250","RC","0536-1366-01","NDC",,,"facility","inpatient","1.000000","UN",,"1.8","1.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOXYMETHYLCELLULOSE SODIUM 0.5 % OP SOLN","81000000","CDM","0250","RC","0536-1386-94","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYVINYL ALCOHOL 1.4 % OP SOLN","81000000","CDM","0250","RC","0536-1408-94","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIPLE VITAMINS-MINERALS PO LIQD","81000000","CDM","0250","RC","0536-2790-59","NDC",,,"facility","inpatient","235.997482","ML",,"18.98","18.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIACINAMIDE 500 MG PO TABS","81000000","CDM","0250","RC","0536-4069-01","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOXINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0536-4406-01","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICOTINE 14 MG/24HR TD PT24","81000000","CDM","0250","RC","0536-5895-88","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICOTINE 21 MG/24HR TD PT24","81000000","CDM","0250","RC","0536-5896-88","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 3 MG PO TABS","81000000","CDM","0250","RC","0536-6412-08","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLEET ENEMA 7-19 GM/118ML PR ENEM","81000000","CDM","0250","RC","0536-7415-51","NDC",,,"facility","inpatient","187.101694","ML",,"1.73","1.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 3 MG PO TABS","81000000","CDM","0250","RC","05388-62808","NDC",,,"facility","inpatient","1.236064","UN",,"1.96","1.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN E 400 UNITS PO CAPS","81000000","CDM","0250","RC","05388-62812","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORDIAZEPOXIDE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","0555-0033-02","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISONIAZID 300 MG PO TABS","81000000","CDM","0250","RC","0555-0071-02","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEDROXYPROGESTERONE ACETATE 2.5 MG PO TABS","81000000","CDM","0250","RC","0555-0872-02","NDC",,,"facility","inpatient","1.000000","UN",,"4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESTRADIOL 1 MG PO TABS","81000000","CDM","0250","RC","0555-0886-02","NDC",,,"facility","inpatient","1.444444","UN",,"9.11","9.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS","81000000","CDM","0250","RC","0555-0972-02","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUDROCORTISONE ACETATE 0.1 MG PO TABS","81000000","CDM","0250","RC","0555-0997-02","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCOSE 40 % PO GEL","81000000","CDM","0250","RC","0574-0070-15","NDC",,,"facility","inpatient","73.728829","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 10 MG MT TROC","81000000","CDM","0250","RC","0574-0107-70","NDC",,,"facility","inpatient","1.024737","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CAFFEINE CITRATE 20 MG/ML PO SOLN","81000000","CDM","0250","RC","0574-0152-80","NDC",,,"facility","inpatient","3.023744","ML",,"34.17","34.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERROUS GLUCONATE 324 (38 FE) MG PO TABS","81000000","CDM","0250","RC","0574-0508-01","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERROUS GLUCONATE 324 (38 FE) MG PO TABS","81000000","CDM","0250","RC","0574-0508-11","NDC",,,"facility","inpatient","1.037036","UN",,"1.99","1.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHARCOAL ACTIVATED PO LIQD","81000000","CDM","0250","RC","0574-0521-74","NDC",,,"facility","inpatient","162.825248","ML",,"1.72","1.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERROUS SULFATE 324 (65 FE) MG PO TBEC","81000000","CDM","0250","RC","0574-0608-01","NDC",,,"facility","inpatient","1.017543","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERROUS SULFATE 324 (65 FE) MG PO TBEC","81000000","CDM","0250","RC","0574-0608-11","NDC",,,"facility","inpatient","1.087911","UN",,"2.01","2.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX POWD","81000000","CDM","0250","RC","0574-2008-15","NDC",,,"facility","inpatient","15.000000","GR",,"137.33","137.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN 5 MG/GM OP OINT","81000000","CDM","0250","RC","0574-4024-11","NDC",,,"facility","inpatient","1.080389","GR",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN 5 MG/GM OP OINT","81000000","CDM","0250","RC","0574-4024-35","NDC",,,"facility","inpatient","4.472222","GM",,"86.99","86.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BISACODYL 10 MG PR SUPP","81000000","CDM","0250","RC","0574-7050-12","NDC",,,"facility","inpatient","1.186998","UN",,"2.00","2.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BISACODYL 10 MG PR SUPP","81000000","CDM","0250","RC","0574-7050-50","NDC",,,"facility","inpatient","1.071428","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE ACETATE 25 MG PR SUPP","81000000","CDM","0250","RC","0574-7090-12","NDC",,,"facility","inpatient","1.000000","UN",,"57.7","57.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 3 MG PO CPEP","81000000","CDM","0250","RC","0574-9855-10","NDC",,,"facility","inpatient","1.339622","UN",,"6.76","6.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL 40 MG PO TABS","81000000","CDM","0250","RC","0591-0404-01","NDC",,,"facility","inpatient","1.173913","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPAFENONE HCL 150 MG PO TABS","81000000","CDM","0250","RC","0591-0582-01","NDC",,,"facility","inpatient","5.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 200 MG PO TABS","81000000","CDM","0250","RC","0591-0606-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.38","10.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BRINZOLAMIDE 1 % OP SUSP","81000000","CDM","0250","RC","0591-2127-79","NDC",,,"facility","inpatient","10.000000","ML",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE","81000000","CDM","0250","RC","0591-2218-26","NDC",,,"facility","inpatient","5.000000","GR",,"89.54","89.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SCOPOLAMINE 1 MG/3DAYS TD PT72","81000000","CDM","0250","RC","0591-2258-04","NDC",,,"facility","inpatient","1.000000","UN",,"97.11","97.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TETRACYCLINE HCL 250 MG PO CAPS","81000000","CDM","0250","RC","0591-2474-01","NDC",,,"facility","inpatient","1.000000","UN",,"31.5","31.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALGANCICLOVIR HCL 50 MG/ML PO SOLR","81000000","CDM","0250","RC","0591-2579-20","NDC",,,"facility","inpatient","88.000917","ML",,"345.01","345.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUTALBITAL-APAP-CAFFEINE 50-300-40 MG PO CAPS","81000000","CDM","0250","RC","0591-2640-01","NDC",,,"facility","inpatient","1.000000","UN",,"16.15","16.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVALBUTEROL TARTRATE 45 MCG/ACT IN AERO","81000000","CDM","0250","RC","0591-2927-54","NDC",,,"facility","inpatient","15.000000","GR",,"368.48","368.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"URSODIOL 300 MG PO CAPS","81000000","CDM","0250","RC","0591-3159-01","NDC",,,"facility","inpatient","1.048192","UN",,"38.83","38.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 150 MG PO TB24","81000000","CDM","0250","RC","0591-3331-30","NDC",,,"facility","inpatient","1.000000","UN",,"28.36","28.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX PTCH","81000000","CDM","0250","RC","0591-3525-30","NDC",,,"facility","inpatient","1.168814","UN",,"42.77","42.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (SR) 100 MG PO TB12","81000000","CDM","0250","RC","0591-3540-60","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (SR) 150 MG PO TB12","81000000","CDM","0250","RC","0591-3541-60","NDC",,,"facility","inpatient","1.214285","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOBENZAPRINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0591-5658-10","NDC",,,"facility","inpatient","1.421052","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12","81000000","CDM","0250","RC","0597-0001-60","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS","81000000","CDM","0250","RC","0597-0024-02","NDC",,,"facility","inpatient","4.000000","GR",,"1761.64","1761.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE 0.3 MG/24HR TD PTWK","81000000","CDM","0250","RC","0597-0033-34","NDC",,,"facility","inpatient","1.000000","UN",,"610.14","610.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEVIRAPINE 200 MG PO TABS","81000000","CDM","0250","RC","0597-0046-60","NDC",,,"facility","inpatient","1.000000","UN",,"54.36","54.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TAMSULOSIN HCL 0.4 MG PO CAPS","81000000","CDM","0250","RC","0597-0058-01","NDC",,,"facility","inpatient","1.050632","UN",,"53.78","53.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS","81000000","CDM","0250","RC","0597-0087-17","NDC",,,"facility","inpatient","12.900000","GR",,"1697.15","1697.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS","81000000","CDM","0250","RC","0597-0100-31","NDC",,,"facility","inpatient","4.000000","GR",,"890.72","890.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS","81000000","CDM","0250","RC","0597-0100-51","NDC",,,"facility","inpatient","4.334943","GR",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS","81000000","CDM","0250","RC","0597-0100-61","NDC",,,"facility","inpatient","4.941176","GR",,"1864.59","1864.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINAGLIPTIN 5 MG PO TABS","81000000","CDM","0250","RC","0597-0140-30","NDC",,,"facility","inpatient","1.000000","UN",,"84.01","84.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINAGLIPTIN 5 MG PO TABS","81000000","CDM","0250","RC","0597-0140-61","NDC",,,"facility","inpatient","1.053872","UN",,"84.01","84.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMPAGLIFLOZIN 10 MG PO TABS","81000000","CDM","0250","RC","0597-0152-37","NDC",,,"facility","inpatient","2.333333","UN",,"97.78","97.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS","81000000","CDM","0250","RC","0597-0183-90","NDC",,,"facility","inpatient","1.000000","UN",,"46.34","46.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DABIGATRAN ETEXILATE MESYLATE 75 MG PO CAPS","81000000","CDM","0250","RC","0597-0355-56","NDC",,,"facility","inpatient","1.800000","UN",,"21.82","21.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DABIGATRAN ETEXILATE MESYLATE 150 MG PO CAPS","81000000","CDM","0250","RC","0597-0360-82","NDC",,,"facility","inpatient","1.167539","UN",,"21.82","21.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM OXIDE 400 MG PO TABS","81000000","CDM","0250","RC","0603-0209-22","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/ML MT SUSP","81000000","CDM","0250","RC","0603-1481-58","NDC",,,"facility","inpatient","488.805347","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX PTCH","81000000","CDM","0250","RC","0603-1880-16","NDC",,,"facility","inpatient","1.152914","UN",,"45.82","45.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 60 MG PO TABS","81000000","CDM","0250","RC","0603-5485-21","NDC",,,"facility","inpatient","2.333333","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN","81000000","CDM","0250","RC","0703-2056-01","NDC",,,"facility","inpatient","10.000000","ML",,"179.4","179.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN","81000000","CDM","0250","RC","0703-2056-03","NDC",,,"facility","inpatient","10.000000","ML",,"179.4","179.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCERIN (LAXATIVE) 2 G PR SUPP","81000000","CDM","0250","RC","0713-0101-25","NDC",,,"facility","inpatient","1.400000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","81000000","CDM","0250","RC","0713-0225-31","NDC",,,"facility","inpatient","30.000000","GR",,"54.6","54.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICONAZOLE NITRATE 2 % VA CREA","81000000","CDM","0250","RC","0713-0252-37","NDC",,,"facility","inpatient","45.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE ACETATE 25 MG PR SUPP","81000000","CDM","0250","RC","0713-0503-24","NDC",,,"facility","inpatient","1.000000","UN",,"10.66","10.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 % PR OINT","81000000","CDM","0250","RC","0713-0564-31","NDC",,,"facility","inpatient","30.000000","GR",,"2075.76","2075.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE","81000000","CDM","0250","RC","0713-0655-40","NDC",,,"facility","inpatient","5.000000","GR",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN","81000000","CDM","0250","RC","0713-0676-53","NDC",,,"facility","inpatient","60.000000","ML",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZINC SULFATE 220 (50 ZN) MG PO CAPS","81000000","CDM","0250","RC","0731-0401-06","NDC",,,"facility","inpatient","1.160000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 100 MCG PO TABS","81000000","CDM","0250","RC","0761-0372-20","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOXINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","0761-0436-20","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOXETINE HCL 20 MG PO CAPS","81000000","CDM","0250","RC","0777-3105-02","NDC",,,"facility","inpatient","1.000000","UN",,"58.36","58.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 0.25 MG PO TABS","81000000","CDM","0250","RC","0781-1061-01","NDC",,,"facility","inpatient","1.000000","UN",,"31.79","31.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","0781-1490-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.86","7.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATENOLOL 50 MG PO TABS","81000000","CDM","0250","RC","0781-1506-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","81000000","CDM","0250","RC","0781-1852-20","NDC",,,"facility","inpatient","1.000000","UN",,"27.79","27.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMTERENE-HCTZ 37.5-25 MG PO CAPS","81000000","CDM","0250","RC","0781-2074-01","NDC",,,"facility","inpatient","1.064516","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 500 MG PO CAPS","81000000","CDM","0250","RC","0781-2613-01","NDC",,,"facility","inpatient","1.235294","UN",,"11.83","11.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN","81000000","CDM","0250","RC","0781-3040-95","NDC",,,"facility","inpatient","2.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN","81000000","CDM","0250","RC","0781-3152-95","NDC",,,"facility","inpatient","10.000000","ML",,"195","195",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 875 MG PO TABS","81000000","CDM","0250","RC","0781-5061-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BROMOCRIPTINE MESYLATE 2.5 MG PO TABS","81000000","CDM","0250","RC","0781-5325-31","NDC",,,"facility","inpatient","1.160000","UN",,"34.47","34.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFPODOXIME PROXETIL 200 MG PO TABS","81000000","CDM","0250","RC","0781-5439-20","NDC",,,"facility","inpatient","1.000000","UN",,"46.51","46.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BRINZOLAMIDE 1 % OP SUSP","81000000","CDM","0250","RC","0781-6014-85","NDC",,,"facility","inpatient","15.000000","ML",,"1646.87","1646.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","0781-6041-58","NDC",,,"facility","inpatient","80.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYBUTYNIN CHLORIDE 5 MG PO TABS","81000000","CDM","0250","RC","0832-0038-01","NDC",,,"facility","inpatient","1.072202","UN",,"14.23","14.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX POWD","81000000","CDM","0250","RC","0832-0465-15","NDC",,,"facility","inpatient","15.000000","GR",,"187.28","187.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BETHANECHOL CHLORIDE 10 MG PO TABS","81000000","CDM","0250","RC","0832-0511-01","NDC",,,"facility","inpatient","1.000000","UN",,"12.26","12.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BETHANECHOL CHLORIDE 25 MG PO TABS","81000000","CDM","0250","RC","0832-0512-01","NDC",,,"facility","inpatient","1.068965","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 1 MG PO TABS","81000000","CDM","0250","RC","0832-1211-00","NDC",,,"facility","inpatient","1.000000","UN",,"7.42","7.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 1 MG PO TABS","81000000","CDM","0250","RC","0832-1211-01","NDC",,,"facility","inpatient","1.047058","UN",,"7.66","7.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 2 MG PO TABS","81000000","CDM","0250","RC","0832-1212-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.99","10.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 2.5 MG PO TABS","81000000","CDM","0250","RC","0832-1213-01","NDC",,,"facility","inpatient","1.170212","UN",,"13.91","13.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 3 MG PO TABS","81000000","CDM","0250","RC","0832-1214-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 4 MG PO TABS","81000000","CDM","0250","RC","0832-1215-01","NDC",,,"facility","inpatient","1.000000","UN",,"12.69","12.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 5 MG PO TABS","81000000","CDM","0250","RC","0832-1216-01","NDC",,,"facility","inpatient","1.016657","UN",,"12.68","12.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 6 MG PO TABS","81000000","CDM","0250","RC","0832-1217-01","NDC",,,"facility","inpatient","1.000000","UN",,"13.75","13.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORPROMAZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0832-6017-00","NDC",,,"facility","inpatient","1.000000","UN",,"23.11","23.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM 500 MG PO TBEC","81000000","CDM","0250","RC","0832-7124-01","NDC",,,"facility","inpatient","1.000000","UN",,"9.91","9.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOPROPYL ALCOHOL 70 % SOLN","81000000","CDM","0250","RC","0869-0810-43","NDC",,,"facility","inpatient","473.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-0201-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASCORBIC ACID 500 MG PO TABS","81000000","CDM","0250","RC","0904-0523-61","NDC",,,"facility","inpatient","1.070796","UN",,"1.69","1.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASCORBIC ACID 500 MG PO TABS","81000000","CDM","0250","RC","0904-0523-80","NDC",,,"facility","inpatient","1.000000","UN",,"1.69","1.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS PO TABS SH","81000000","CDM","0250","RC","0904-0539-61","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 250 MG PO TABS","81000000","CDM","0250","RC","0904-1453-61","NDC",,,"facility","inpatient","1.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OYSTER SHELL CALCIUM/VITAMIN D 250-3.125 MG-MCG PO TABS","81000000","CDM","0250","RC","0904-1882-60","NDC",,,"facility","inpatient","1.000000","UN",,"1.02","1.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OYSTER CALCIUM CARB 1250 MG / 500 MG ELEMENTAL PO TABS SH","81000000","CDM","0250","RC","0904-1883-61","NDC",,,"facility","inpatient","1.057745","UN",,"1.52","1.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 50 MG PO CAPS","81000000","CDM","0250","RC","0904-2056-61","NDC",,,"facility","inpatient","1.000000","UN","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DIPHENHYDRAMINE HCL 50 MG PO CAPS","81000000","CDM","0250","RC","0904-2056-61","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN A 3 MG (10000 UT) PO CAPS","81000000","CDM","0250","RC","0904-2085-60","NDC",,,"facility","inpatient","1.018850","UN",,"1.83","1.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIACIN 500 MG PO TABS","81000000","CDM","0250","RC","0904-2272-60","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALAMINE 8-8 % EX LOTN","81000000","CDM","0250","RC","0904-2533-21","NDC",,,"facility","inpatient","168.200000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS","81000000","CDM","0250","RC","0904-2725-61","NDC",,,"facility","inpatient","1.047926","UN",,"13.16","13.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYBUTYNIN CHLORIDE 5 MG PO TABS","81000000","CDM","0250","RC","0904-2821-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBAMAZEPINE 100 MG PO CHEW","81000000","CDM","0250","RC","0904-3854-61","NDC",,,"facility","inpatient","1.000000","UN",,"12.35","12.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SALINE NASAL SPRAY 0.65 % NA SOLN","81000000","CDM","0250","RC","0904-3865-75","NDC",,,"facility","inpatient","45.614678","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PSEUDOEPHEDRINE HCL 30 MG PO TABS","81000000","CDM","0250","RC","0904-5053-59","NDC",,,"facility","inpatient","1.000000","UN",,"1","1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CITRATE 950 (200 CA) MG PO TABS","81000000","CDM","0250","RC","0904-5062-60","NDC",,,"facility","inpatient","1.238805","UN",,"1.08","1.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","81000000","CDM","0250","RC","0904-5174-16","NDC",,,"facility","inpatient","473.030821","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","0904-5306-61","NDC",,,"facility","inpatient","1.000000","UN",,"1.83","1.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 50 MG PO CAPS","81000000","CDM","0250","RC","0904-5307-80","NDC",,,"facility","inpatient","1.266666","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRENATAL VITAMINS+FOLATE PO TABS SH","81000000","CDM","0250","RC","0904-5313-46","NDC",,,"facility","inpatient","1.033426","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRENATAL VITAMINS+FOLATE PO TABS SH","81000000","CDM","0250","RC","0904-5313-60","NDC",,,"facility","inpatient","1.073962","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENTOXIFYLLINE ER 400 MG PO TBCR","81000000","CDM","0250","RC","0904-5448-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","81000000","CDM","0250","RC","0904-5492-61","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXAZOSIN MESYLATE 4 MG PO TABS","81000000","CDM","0250","RC","0904-5524-61","NDC",,,"facility","inpatient","1.203389","UN",,"11.45","11.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10 MG PO TABS","81000000","CDM","0250","RC","0904-5529-52","NDC",,,"facility","inpatient","1.000000","UN",,"1.24","1.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOXETINE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","0904-5784-61","NDC",,,"facility","inpatient","1.059259","UN",,"13.67","13.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOXETINE HCL 20 MG PO CAPS","81000000","CDM","0250","RC","0904-5785-61","NDC",,,"facility","inpatient","1.100628","UN",,"13.95","13.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 200 MG PO CAPS","81000000","CDM","0250","RC","0904-5789-61","NDC",,,"facility","inpatient","1.024046","UN",,"8.96","8.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 400 MG PO TABS","81000000","CDM","0250","RC","0904-5790-61","NDC",,,"facility","inpatient","1.000000","UN","PN","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ACYCLOVIR 400 MG PO TABS","81000000","CDM","0250","RC","0904-5790-61","NDC",,,"facility","inpatient","1.037765","UN",,"14.95","14.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLECALCIFEROL 10 MCG (400 UNIT) PO TABS","81000000","CDM","0250","RC","0904-5823-60","NDC",,,"facility","inpatient","1.000000","UN",,"1.56","1.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLECALCIFEROL 25 MCG (1000 UT) PO TABS","81000000","CDM","0250","RC","0904-5824-60","NDC",,,"facility","inpatient","1.177777","UN",,"1.13","1.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IBUPROFEN 400 MG PO TABS","81000000","CDM","0250","RC","0904-5853-61","NDC",,,"facility","inpatient","1.500000","UN",,"5.06","5.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IBUPROFEN 600 MG PO TABS","81000000","CDM","0250","RC","0904-5854-61","NDC",,,"facility","inpatient","1.928571","UN",,"10.1","10.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAVASTATIN SODIUM 10 MG PO TABS","81000000","CDM","0250","RC","0904-5891-61","NDC",,,"facility","inpatient","1.097560","UN",,"15.91","15.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAVASTATIN SODIUM 20 MG PO TABS","81000000","CDM","0250","RC","0904-5892-61","NDC",,,"facility","inpatient","1.044027","UN",,"13.98","13.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAVASTATIN SODIUM 40 MG PO TABS","81000000","CDM","0250","RC","0904-5893-61","NDC",,,"facility","inpatient","1.043243","UN",,"21.28","21.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 125 MCG PO TABS","81000000","CDM","0250","RC","0904-5921-61","NDC",,,"facility","inpatient","1.038043","UN",,"12.75","12.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 250 MCG PO TABS","81000000","CDM","0250","RC","0904-5922-61","NDC",,,"facility","inpatient","1.000000","UN",,"9.27","9.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMMONIUM LACTATE 12 % EX LOTN","81000000","CDM","0250","RC","0904-5984-26","NDC",,,"facility","inpatient","226.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 0.5 MG PO TABS","81000000","CDM","0250","RC","0904-6007-61","NDC",,,"facility","inpatient","1.143014","UN",,"37.26","37.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 1 MG PO TABS","81000000","CDM","0250","RC","0904-6008-61","NDC",,,"facility","inpatient","2.636363","UN","PN","32.10","32.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LORAZEPAM 1 MG PO TABS","81000000","CDM","0250","RC","0904-6008-61","NDC",,,"facility","inpatient","1.242904","UN",,"28.12","28.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BICALUTAMIDE 50 MG PO TABS","81000000","CDM","0250","RC","0904-6019-46","NDC",,,"facility","inpatient","1.000000","UN",,"107.02","107.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZOLPIDEM TARTRATE 5 MG PO TABS","81000000","CDM","0250","RC","0904-6082-61","NDC",,,"facility","inpatient","1.134078","UN",,"29.40","29.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CITALOPRAM HYDROBROMIDE 10 MG PO TABS","81000000","CDM","0250","RC","0904-6084-61","NDC",,,"facility","inpatient","1.099502","UN",,"13.81","13.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CITALOPRAM HYDROBROMIDE 20 MG PO TABS","81000000","CDM","0250","RC","0904-6085-61","NDC",,,"facility","inpatient","1.035555","UN",,"14.92","14.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBAMAZEPINE 200 MG PO TABS","81000000","CDM","0250","RC","0904-6172-61","NDC",,,"facility","inpatient","1.046783","UN",,"10.80","10.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA 25-250 MG PO TABS","81000000","CDM","0250","RC","0904-6238-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOPERAMIDE HCL 1 MG/7.5ML PO SOLN","81000000","CDM","0250","RC","0904-6256-20","NDC",,,"facility","inpatient","124.824120","ML",,"14.83","14.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZIPRASIDONE HCL 20 MG PO CAPS","81000000","CDM","0250","RC","0904-6269-45","NDC",,,"facility","inpatient","1.000000","UN",,"18.21","18.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZIPRASIDONE HCL 40 MG PO CAPS","81000000","CDM","0250","RC","0904-6270-45","NDC",,,"facility","inpatient","1.000000","UN",,"18.21","18.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 10 MG PO TABS","81000000","CDM","0250","RC","0904-6290-61","NDC",,,"facility","inpatient","1.063770","UN",,"11.35","11.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 20 MG PO TABS","81000000","CDM","0250","RC","0904-6291-61","NDC",,,"facility","inpatient","1.068304","UN",,"12.00","12.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 40 MG PO TABS","81000000","CDM","0250","RC","0904-6292-06","NDC",,,"facility","inpatient","1.078175","UN",,"10.97","10.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 40 MG PO TABS","81000000","CDM","0250","RC","0904-6292-61","NDC",,,"facility","inpatient","1.100466","UN",,"11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 80 MG PO TABS","81000000","CDM","0250","RC","0904-6293-04","NDC",,,"facility","inpatient","1.052064","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOPIDOGREL BISULFATE 75 MG PO TABS","81000000","CDM","0250","RC","0904-6294-61","NDC",,,"facility","inpatient","1.113578","UN",,"23.08","23.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 3.125 MG PO TABS","81000000","CDM","0250","RC","0904-6300-61","NDC",,,"facility","inpatient","1.068094","UN",,"12.58","12.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 6.25 MG PO TABS","81000000","CDM","0250","RC","0904-6301-61","NDC",,,"facility","inpatient","1.062409","UN",,"10.53","10.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 12.5 MG PO TABS","81000000","CDM","0250","RC","0904-6302-61","NDC",,,"facility","inpatient","1.042801","UN",,"12.82","12.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 25 MG PO TABS","81000000","CDM","0250","RC","0904-6303-61","NDC",,,"facility","inpatient","1.095364","UN",,"14.61","14.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOL 1.4 % MT LIQD","81000000","CDM","0250","RC","0904-6305-21","NDC",,,"facility","inpatient","177.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 25 MG PO TB24","81000000","CDM","0250","RC","0904-6322-06","NDC",,,"facility","inpatient","1.125160","UN",,"12.74","12.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 25 MG PO TB24","81000000","CDM","0250","RC","0904-6322-61","NDC",,,"facility","inpatient","1.000000","UN",,"10.66","10.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 50 MG PO TB24","81000000","CDM","0250","RC","0904-6323-61","NDC",,,"facility","inpatient","1.166120","UN",,"10.53","10.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 100 MG PO TB24","81000000","CDM","0250","RC","0904-6324-61","NDC",,,"facility","inpatient","5.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 250 MG PO TABS","81000000","CDM","0250","RC","0904-6351-61","NDC",,,"facility","inpatient","1.140350","UN",,"53.66","53.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 500 MG PO TABS","81000000","CDM","0250","RC","0904-6352-61","NDC",,,"facility","inpatient","1.150943","UN",,"58.17","58.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 750 MG PO TABS","81000000","CDM","0250","RC","0904-6353-61","NDC",,,"facility","inpatient","1.032000","UN",,"98.46","98.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 0.5 MG PO TABS","81000000","CDM","0250","RC","0904-6358-61","NDC",,,"facility","inpatient","1.000000","UN",,"21.63","21.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 1 MG PO TABS","81000000","CDM","0250","RC","0904-6359-61","NDC",,,"facility","inpatient","2.156250","UN",,"12.04","12.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 2 MG PO TABS","81000000","CDM","0250","RC","0904-6360-61","NDC",,,"facility","inpatient","1.000000","UN",,"37.44","37.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 3 MG PO TABS","81000000","CDM","0250","RC","0904-6361-61","NDC",,,"facility","inpatient","1.000000","UN",,"45.67","45.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 4 MG PO TABS","81000000","CDM","0250","RC","0904-6362-61","NDC",,,"facility","inpatient","1.000000","UN",,"44.38","44.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM ER 500 MG PO TB24","81000000","CDM","0250","RC","0904-6364-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMLODIPINE BESYLATE 2.5 MG PO TABS","81000000","CDM","0250","RC","0904-6369-61","NDC",,,"facility","inpatient","1.000000","UN",,"10.86","10.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMLODIPINE BESYLATE 5 MG PO TABS","81000000","CDM","0250","RC","0904-6370-61","NDC",,,"facility","inpatient","1.000000","UN","PN","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"AMLODIPINE BESYLATE 5 MG PO TABS","81000000","CDM","0250","RC","0904-6370-61","NDC",,,"facility","inpatient","1.078673","UN",,"12.06","12.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMLODIPINE BESYLATE 10 MG PO TABS","81000000","CDM","0250","RC","0904-6371-61","NDC",,,"facility","inpatient","1.063815","UN",,"15.00","15.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 0.25 MG PO TABS","81000000","CDM","0250","RC","0904-6373-61","NDC",,,"facility","inpatient","1.000000","UN",,"14.65","14.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 1 MG PO TABS","81000000","CDM","0250","RC","0904-6374-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BISACODYL 5 MG PO TBEC","81000000","CDM","0250","RC","0904-6407-61","NDC",,,"facility","inpatient","1.055913","UN",,"0.72","0.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CARBONATE ANTACID 500 MG PO CHEW","81000000","CDM","0250","RC","0904-6412-92","NDC",,,"facility","inpatient","1.085836","UN",,"1.31","1.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 10 MG PO TABS","81000000","CDM","0250","RC","0904-6426-61","NDC",,,"facility","inpatient","1.079207","UN",,"21.91","21.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 20 MG PO TABS","81000000","CDM","0250","RC","0904-6427-61","NDC",,,"facility","inpatient","1.091428","UN",,"24.20","24.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TEMAZEPAM 7.5 MG PO CAPS","81000000","CDM","0250","RC","0904-6436-04","NDC",,,"facility","inpatient","1.074766","UN",,"27.46","27.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-6441-61","NDC",,,"facility","inpatient","1.166666","UN",,"13.93","13.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","0904-6442-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","0904-6443-61","NDC",,,"facility","inpatient","1.045801","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE MONONITRATE ER 30 MG PO TB24","81000000","CDM","0250","RC","0904-6449-61","NDC",,,"facility","inpatient","1.097382","UN",,"12.49","12.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE MONONITRATE ER 60 MG PO TB24","81000000","CDM","0250","RC","0904-6450-61","NDC",,,"facility","inpatient","1.072234","UN",,"13.51","13.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOPIDOGREL BISULFATE 300 MG PO TABS","81000000","CDM","0250","RC","0904-6467-07","NDC",,,"facility","inpatient","1.483516","UN",,"62.96","62.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 10 MG PO TABS","81000000","CDM","0250","RC","0904-6475-61","NDC",,,"facility","inpatient","1.065684","UN",,"11.47","11.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARTIFICIAL TEARS OP OINT - CONSOLIDATED","81000000","CDM","0250","RC","0904-6488-38","NDC",,,"facility","inpatient","3.500000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 100 MG PO TABS","81000000","CDM","0250","RC","0904-6500-61","NDC",,,"facility","inpatient","1.002390","UN",,"44.61","44.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","0904-6501-61","NDC",,,"facility","inpatient","1.025794","UN",,"58.71","58.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CELECOXIB 100 MG PO CAPS","81000000","CDM","0250","RC","0904-6502-61","NDC",,,"facility","inpatient","1.000000","UN",,"24.01","24.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CELECOXIB 200 MG PO CAPS","81000000","CDM","0250","RC","0904-6503-61","NDC",,,"facility","inpatient","1.210526","UN",,"41.68","41.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEMANTINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0904-6505-61","NDC",,,"facility","inpatient","1.000000","UN",,"13.57","13.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 5 MG PO TABS","81000000","CDM","0250","RC","0904-6510-06","NDC",,,"facility","inpatient","1.362264","UN",,"49.66","49.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MECLIZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-6517-61","NDC",,,"facility","inpatient","1.068965","UN",,"2.76","2.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SENNA 8.6 MG PO TABS","81000000","CDM","0250","RC","0904-6522-61","NDC",,,"facility","inpatient","1.000000","UN",,"0.83","0.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 10 MG PO TABS","81000000","CDM","0250","RC","0904-6550-61","NDC",,,"facility","inpatient","1.189873","UN",,"10.95","10.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE ER 30 MG PO TBCR","81000000","CDM","0250","RC","0904-6558-61","NDC",,,"facility","inpatient","1.024767","UN",,"28.93","28.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZONATATE 100 MG PO CAPS","81000000","CDM","0250","RC","0904-6564-60","NDC",,,"facility","inpatient","1.111111","UN",,"13.64","13.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 300 MG PO TABS","81000000","CDM","0250","RC","0904-6572-61","NDC",,,"facility","inpatient","1.083989","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL 32.4 MG PO TABS","81000000","CDM","0250","RC","0904-6575-61","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMIVUDINE 150 MG PO TABS","81000000","CDM","0250","RC","0904-6583-04","NDC",,,"facility","inpatient","1.000000","UN",,"45.77","45.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 50 MG PO TABS","81000000","CDM","0250","RC","0904-6596-04","NDC",,,"facility","inpatient","1.000000","UN",,"36.54","36.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM 125 MG PO CSDR","81000000","CDM","0250","RC","0904-6615-61","NDC",,,"facility","inpatient","1.209790","UN",,"6.15","6.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-6617-61","NDC",,,"facility","inpatient","1.071174","UN",,"11.69","11.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","0904-6618-61","NDC",,,"facility","inpatient","1.000000","UN",,"12.79","12.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 10 MG PO TABS","81000000","CDM","0250","RC","0904-6619-61","NDC",,,"facility","inpatient","1.016376","UN",,"9.93","9.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 20 MG PO TABS","81000000","CDM","0250","RC","0904-6620-61","NDC",,,"facility","inpatient","1.000000","UN",,"12.55","12.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOSTIGMINE BROMIDE 60 MG PO TABS","81000000","CDM","0250","RC","0904-6622-61","NDC",,,"facility","inpatient","1.110091","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBAMIDE PEROXIDE 6.5 % OT SOLN","81000000","CDM","0250","RC","0904-6627-35","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL 75 MG PO TABS","81000000","CDM","0250","RC","0904-6635-61","NDC",,,"facility","inpatient","1.073226","UN",,"12.25","12.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLIPIZIDE 5 MG PO TABS","81000000","CDM","0250","RC","0904-6637-61","NDC",,,"facility","inpatient","1.074074","UN",,"14.33","14.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUETIAPINE FUMARATE 25 MG PO TABS","81000000","CDM","0250","RC","0904-6638-61","NDC",,,"facility","inpatient","1.000000","UN",,"4.71","4.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUETIAPINE FUMARATE 100 MG PO TABS","81000000","CDM","0250","RC","0904-6640-61","NDC",,,"facility","inpatient","1.000000","UN",,"6.37","6.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE 250 MG PO TABS","81000000","CDM","0250","RC","0904-6663-61","NDC",,,"facility","inpatient","1.000000","UN",,"23.83","23.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 100 MG PO CAPS","81000000","CDM","0250","RC","0904-6665-61","NDC",,,"facility","inpatient","1.044389","UN",,"10.53","10.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 300 MG PO CAPS","81000000","CDM","0250","RC","0904-6666-61","NDC",,,"facility","inpatient","1.053656","UN",,"10.96","10.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOFETILIDE 125 MCG PO CAPS","81000000","CDM","0250","RC","0904-6681-08","NDC",,,"facility","inpatient","1.470588","UN",,"34.07","34.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOFETILIDE 250 MCG PO CAPS","81000000","CDM","0250","RC","0904-6682-08","NDC",,,"facility","inpatient","1.400000","UN",,"34.41","34.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METFORMIN HCL 500 MG PO TABS","81000000","CDM","0250","RC","0904-6689-61","NDC",,,"facility","inpatient","1.500000","UN",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 20 MG PO TABS","81000000","CDM","0250","RC","0904-6705-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS","81000000","CDM","0250","RC","0904-6706-06","NDC",,,"facility","inpatient","1.100000","UN",,"1.35","1.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 800 MG PO TABS","81000000","CDM","0250","RC","0904-6707-06","NDC",,,"facility","inpatient","1.010364","UN",,"18.88","18.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 800 MG PO TABS","81000000","CDM","0250","RC","0904-6707-82","NDC",,,"facility","inpatient","1.064516","UN",,"27.40","27.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 250 MG PO TABS","81000000","CDM","0250","RC","0904-6708-06","NDC",,,"facility","inpatient","1.000000","UN",,"9.13","9.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 1 MG PO TABS","81000000","CDM","0250","RC","0904-6709-61","NDC",,,"facility","inpatient","1.250000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETIRIZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0904-6717-61","NDC",,,"facility","inpatient","1.000000","UN","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CETIRIZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0904-6717-61","NDC",,,"facility","inpatient","1.024906","UN",,"1.93","1.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SENNA 8.6 MG PO TABS","81000000","CDM","0250","RC","0904-6725-59","NDC",,,"facility","inpatient","1.183606","UN",,"1.45","1.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PSEUDOEPHEDRINE HCL 60 MG PO TABS","81000000","CDM","0250","RC","0904-6728-46","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 500 MG PO TABS","81000000","CDM","0250","RC","0904-6730-61","NDC",,,"facility","inpatient","1.000000","UN","PN","10.06","10.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ACETAMINOPHEN 500 MG PO TABS","81000000","CDM","0250","RC","0904-6730-61","NDC",,,"facility","inpatient","1.764705","UN",,"5.13","5.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HALOPERIDOL 10 MG PO TABS","81000000","CDM","0250","RC","0904-6733-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BISACODYL 5 MG PO TBEC","81000000","CDM","0250","RC","0904-6748-60","NDC",,,"facility","inpatient","1.000000","UN",,"0.89","0.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","0904-6761-30","NDC",,,"facility","inpatient","30.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORATADINE 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","0904-6767-20","NDC",,,"facility","inpatient","120.004800","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 325 MG PO TABS","81000000","CDM","0250","RC","0904-6773-61","NDC",,,"facility","inpatient","1.000000","UN","PN","5.04","5.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ACETAMINOPHEN 325 MG PO TABS","81000000","CDM","0250","RC","0904-6773-61","NDC",,,"facility","inpatient","1.646464","UN",,"5.11","5.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROSUVASTATIN CALCIUM 20 MG PO TABS","81000000","CDM","0250","RC","0904-6780-61","NDC",,,"facility","inpatient","1.000000","UN",,"8.14","8.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HALOPERIDOL 5 MG PO TABS","81000000","CDM","0250","RC","0904-6782-61","NDC",,,"facility","inpatient","1.740740","UN",,"14.4","14.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZTROPINE MESYLATE 2 MG PO TABS","81000000","CDM","0250","RC","0904-6789-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MODAFINIL 100 MG PO TABS","81000000","CDM","0250","RC","0904-6791-04","NDC",,,"facility","inpatient","1.000000","UN",,"46.47","46.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASPIRIN 81 MG PO CHEW","81000000","CDM","0250","RC","0904-6794-89","NDC",,,"facility","inpatient","3.666666","UN",,"5.04","5.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 5 MG PO TABS","81000000","CDM","0250","RC","0904-6797-61","NDC",,,"facility","inpatient","1.122448","UN",,"14.20","14.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 10 MG PO TABS","81000000","CDM","0250","RC","0904-6798-61","NDC",,,"facility","inpatient","1.121134","UN",,"8.49","8.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 20 MG PO TABS","81000000","CDM","0250","RC","0904-6799-61","NDC",,,"facility","inpatient","1.124031","UN",,"10.98","10.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MONTELUKAST SODIUM 10 MG PO TABS","81000000","CDM","0250","RC","0904-6808-06","NDC",,,"facility","inpatient","1.117647","UN","PN","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MONTELUKAST SODIUM 10 MG PO TABS","81000000","CDM","0250","RC","0904-6808-06","NDC",,,"facility","inpatient","1.076099","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MONTELUKAST SODIUM 10 MG PO TABS","81000000","CDM","0250","RC","0904-6808-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 2.5 MG PO TABS","81000000","CDM","0250","RC","0904-6817-06","NDC",,,"facility","inpatient","1.057971","UN",,"10.22","10.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0904-6818-06","NDC",,,"facility","inpatient","1.075098","UN",,"8.48","8.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","0904-6818-61","NDC",,,"facility","inpatient","1.053452","UN",,"9.77","9.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0904-6819-07","NDC",,,"facility","inpatient","1.032128","UN",,"12.88","12.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS","81000000","CDM","0250","RC","0904-6821-04","NDC",,,"facility","inpatient","1.000000","UN",,"31.13","31.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 600 MG PO TABS","81000000","CDM","0250","RC","0904-6823-61","NDC",,,"facility","inpatient","1.083832","UN",,"14.07","14.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","0904-6824-61","NDC",,,"facility","inpatient","1.036231","UN",,"39.52","39.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS","81000000","CDM","0250","RC","0904-6825-61","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCYTOSINE 250 MG PO CAPS","81000000","CDM","0250","RC","0904-6834-07","NDC",,,"facility","inpatient","1.000000","UN",,"301.19","301.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOPERAMIDE HCL 1 MG/7.5ML PO SOLN","81000000","CDM","0250","RC","0904-6836-20","NDC",,,"facility","inpatient","120.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORATADINE 10 MG PO TABS","81000000","CDM","0250","RC","0904-6852-61","NDC",,,"facility","inpatient","1.032786","UN","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DIVALPROEX SODIUM 250 MG PO TBEC","81000000","CDM","0250","RC","0904-6860-61","NDC",,,"facility","inpatient","1.355029","UN",,"6.36","6.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAZODONE HCL 50 MG PO TABS","81000000","CDM","0250","RC","0904-6868-61","NDC",,,"facility","inpatient","1.054560","UN",,"11.82","11.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAZODONE HCL 100 MG PO TABS","81000000","CDM","0250","RC","0904-6869-61","NDC",,,"facility","inpatient","1.000000","UN",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","81000000","CDM","0250","RC","0904-6870-45","NDC",,,"facility","inpatient","1.044966","UN",,"14.98","14.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OMEPRAZOLE 20 MG PO CPDR","81000000","CDM","0250","RC","0904-6917-61","NDC",,,"facility","inpatient","1.391304","UN",,"1.51","1.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-6924-61","NDC",,,"facility","inpatient","1.078873","UN",,"11.36","11.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","0904-6926-61","NDC",,,"facility","inpatient","1.142857","UN",,"13.90","13.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 25 MG PO TABS","81000000","CDM","0250","RC","0904-6927-61","NDC",,,"facility","inpatient","1.000000","UN",,"13.47","13.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOPIRAMATE 25 MG PO TABS","81000000","CDM","0250","RC","0904-6928-61","NDC",,,"facility","inpatient","1.800000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYETHYLENE GLYCOL 3350 17 G PO PACK","81000000","CDM","0250","RC","0904-6931-26","NDC",,,"facility","inpatient","1.248210","UN",,"1.89","1.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","0904-6987-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 20 MG PO TABS","81000000","CDM","0250","RC","0904-6988-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PSEUDOEPHEDRINE HCL 30 MG PO TABS","81000000","CDM","0250","RC","0904-6990-61","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 25 MG PO CAPS","81000000","CDM","0250","RC","0904-6991-61","NDC",,,"facility","inpatient","1.182978","UN",,"26.32","26.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 50 MG PO CAPS","81000000","CDM","0250","RC","0904-6992-61","NDC",,,"facility","inpatient","1.039215","UN",,"29.03","29.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 200 MG PO TABS","81000000","CDM","0250","RC","0904-6993-61","NDC",,,"facility","inpatient","1.066945","UN",,"11.06","11.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 250 MG PO CAPS","81000000","CDM","0250","RC","0904-6999-80","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 100 MG PO CAPS","81000000","CDM","0250","RC","0904-7001-61","NDC",,,"facility","inpatient","1.000000","UN",,"21.61","21.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","0904-7006-35","NDC",,,"facility","inpatient","18.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE 25 MG PO TABS","81000000","CDM","0250","RC","0904-7007-61","NDC",,,"facility","inpatient","1.057692","UN",,"7.19","7.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE 100 MG PO TABS","81000000","CDM","0250","RC","0904-7008-61","NDC",,,"facility","inpatient","1.097326","UN",,"8.29","8.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 1 MG PO TABS","81000000","CDM","0250","RC","0904-7016-04","NDC",,,"facility","inpatient","1.000000","UN",,"13.93","13.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAZOSIN HCL 2 MG PO CAPS","81000000","CDM","0250","RC","0904-7021-61","NDC",,,"facility","inpatient","1.235294","UN",,"14.10","14.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN ZINC 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","0904-7023-67","NDC",,,"facility","inpatient","1.011267","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","0904-7024-04","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALTREXONE HCL 50 MG PO TABS","81000000","CDM","0250","RC","0904-7036-04","NDC",,,"facility","inpatient","1.210526","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 100 MG PO TABS","81000000","CDM","0250","RC","0904-7041-61","NDC",,,"facility","inpatient","1.061855","UN",,"14.09","14.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMANTADINE HCL 100 MG PO CAPS","81000000","CDM","0250","RC","0904-7042-06","NDC",,,"facility","inpatient","1.260869","UN",,"14.04","14.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMANTADINE HCL 100 MG PO CAPS","81000000","CDM","0250","RC","0904-7042-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 20 MG PO CPEP","81000000","CDM","0250","RC","0904-7043-04","NDC",,,"facility","inpatient","1.021739","UN",,"11.16","11.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 30 MG PO CPEP","81000000","CDM","0250","RC","0904-7044-61","NDC",,,"facility","inpatient","1.061293","UN",,"13.06","13.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 60 MG PO CPEP","81000000","CDM","0250","RC","0904-7045-61","NDC",,,"facility","inpatient","1.111576","UN",,"14.45","14.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 50 MG PO TABS","81000000","CDM","0250","RC","0904-7048-61","NDC",,,"facility","inpatient","1.031250","UN",,"10.48","10.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXEPIN HCL 100 MG PO CAPS","81000000","CDM","0250","RC","0904-7055-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NADOLOL 40 MG PO TABS","81000000","CDM","0250","RC","0904-7071-07","NDC",,,"facility","inpatient","1.000000","UN",,"21.79","21.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL ER 37.5 MG PO CP24","81000000","CDM","0250","RC","0904-7075-61","NDC",,,"facility","inpatient","1.163265","UN",,"14.15","14.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL ER 150 MG PO CP24","81000000","CDM","0250","RC","0904-7076-61","NDC",,,"facility","inpatient","1.160000","UN",,"12.39","12.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 500 MG PO TABS","81000000","CDM","0250","RC","0904-7083-61","NDC",,,"facility","inpatient","1.037914","UN",,"14.39","14.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 150 MG PO TB24","81000000","CDM","0250","RC","0904-7084-04","NDC",,,"facility","inpatient","1.055749","UN",,"12.55","12.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS","81000000","CDM","0250","RC","0904-7095-61","NDC",,,"facility","inpatient","1.000000","UN",,"39.06","39.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CAPTOPRIL 25 MG PO TABS","81000000","CDM","0250","RC","0904-7106-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 100 MG PO TABS","81000000","CDM","0250","RC","0904-7109-61","NDC",,,"facility","inpatient","1.025711","UN",,"9.91","9.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 200 MG PO TABS","81000000","CDM","0250","RC","0904-7110-61","NDC",,,"facility","inpatient","1.032258","UN",,"12.01","12.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 300 MG PO TABS","81000000","CDM","0250","RC","0904-7111-61","NDC",,,"facility","inpatient","1.093930","UN",,"11.14","11.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLCHICINE 0.6 MG PO TABS","81000000","CDM","0250","RC","0904-7120-04","NDC",,,"facility","inpatient","1.000000","UN",,"31.66","31.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 500 MG PO TABS","81000000","CDM","0250","RC","0904-7124-61","NDC",,,"facility","inpatient","1.077992","UN",,"10.42","10.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG PO TABS","81000000","CDM","0250","RC","0904-7126-61","NDC",,,"facility","inpatient","1.031500","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORPROMAZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","0904-7129-61","NDC",,,"facility","inpatient","1.000000","UN",,"18.08","18.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORPROMAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-7130-06","NDC",,,"facility","inpatient","1.000000","UN",,"16.49","16.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORPROMAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-7130-61","NDC",,,"facility","inpatient","1.266666","UN",,"34.37","34.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORPROMAZINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","0904-7132-61","NDC",,,"facility","inpatient","1.800000","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOLAZONE 5 MG PO TABS","81000000","CDM","0250","RC","0904-7139-61","NDC",,,"facility","inpatient","1.000000","UN",,"21.36","21.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZONATATE 100 MG PO CAPS","81000000","CDM","0250","RC","0904-7153-61","NDC",,,"facility","inpatient","1.058506","UN",,"12.59","12.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METFORMIN HCL 500 MG PO TABS","81000000","CDM","0250","RC","0904-7162-61","NDC",,,"facility","inpatient","1.043478","UN",,"10.60","10.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"URSODIOL 300 MG PO CAPS","81000000","CDM","0250","RC","0904-7168-61","NDC",,,"facility","inpatient","1.018230","UN",,"27.45","27.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 20 MG PO TABS","81000000","CDM","0250","RC","0904-7177-61","NDC",,,"facility","inpatient","1.210526","UN",,"13.52","13.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAMADOL HCL 50 MG PO TABS","81000000","CDM","0250","RC","0904-7179-61","NDC",,,"facility","inpatient","1.075977","UN",,"39.30","39.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 100 MG PO CAPS","81000000","CDM","0250","RC","0904-7183-61","NDC",,,"facility","inpatient","1.111988","UN",,"1.64","1.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-7184-61","NDC",,,"facility","inpatient","1.417910","UN",,"14.56","14.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","0904-7185-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATENOLOL 25 MG PO TABS","81000000","CDM","0250","RC","0904-7187-61","NDC",,,"facility","inpatient","1.168224","UN",,"9.80","9.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 10 MG PO TABS","81000000","CDM","0250","RC","0904-7188-61","NDC",,,"facility","inpatient","1.021680","UN",,"13.52","13.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEBIVOLOL HCL 5 MG PO TABS","81000000","CDM","0250","RC","0904-7189-04","NDC",,,"facility","inpatient","1.000000","UN",,"18.48","18.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 20 MG PO TABS","81000000","CDM","0250","RC","0904-7193-61","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN HCL 300 MG PO CAPS","81000000","CDM","0250","RC","0904-7194-61","NDC",,,"facility","inpatient","1.087912","UN",,"14.02","14.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 40 MG PO TABS","81000000","CDM","0250","RC","0904-7200-61","NDC",,,"facility","inpatient","1.078431","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DANTROLENE SODIUM 25 MG PO CAPS","81000000","CDM","0250","RC","0904-7211-04","NDC",,,"facility","inpatient","1.000000","UN",,"11.85","11.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (SR) 150 MG PO TB12","81000000","CDM","0250","RC","0904-7214-61","NDC",,,"facility","inpatient","1.078602","UN",,"13.34","13.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOLIC ACID 1 MG PO TABS","81000000","CDM","0250","RC","0904-7224-61","NDC",,,"facility","inpatient","1.068461","UN",,"1.97","1.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","0904-7237-61","NDC",,,"facility","inpatient","1.267123","UN",,"1.77","1.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","0904-7237-61","NDC",,,"facility","inpatient","1.144329","UN","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"SODIUM CHLORIDE 1 G PO TABS","81000000","CDM","0250","RC","0904-7239-61","NDC",,,"facility","inpatient","1.084033","UN",,"1.39","1.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 500 MG PO TABS","81000000","CDM","0250","RC","0904-7243-61","NDC",,,"facility","inpatient","1.022068","UN",,"14.79","14.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 50 MG PO TABS","81000000","CDM","0250","RC","0904-7244-68","NDC",,,"facility","inpatient","1.080402","UN",,"15.06","15.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 100 MG PO TABS","81000000","CDM","0250","RC","0904-7245-68","NDC",,,"facility","inpatient","1.040609","UN",,"27.5","27.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 200 MG PO TABS","81000000","CDM","0250","RC","0904-7247-68","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SENNA 8.6 MG PO TABS","81000000","CDM","0250","RC","0904-7252-61","NDC",,,"facility","inpatient","1.096343","UN",,"1.37","1.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA 25-100 MG PO TABS","81000000","CDM","0250","RC","0904-7257-61","NDC",,,"facility","inpatient","1.100000","UN",,"9.26","9.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXCARBAZEPINE 300 MG PO TABS","81000000","CDM","0250","RC","0904-7263-61","NDC",,,"facility","inpatient","1.428571","UN",,"6.47","6.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/ML MT SUSP","81000000","CDM","0250","RC","0904-7276-70","NDC",,,"facility","inpatient","5.220853","ML",,"29.94","29.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 160 MG/5ML PO SUSP (PEDIATRIC)","81000000","CDM","0250","RC","0904-7278-70","NDC",,,"facility","inpatient","5.000000","ML",,"5.39","5.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 150 MG/15ML PO LIQD","81000000","CDM","0250","RC","0904-7279-66","NDC",,,"facility","inpatient","10.911680","ML",,"1.28","1.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 250 MG PO CAPS","81000000","CDM","0250","RC","0904-7281-60","NDC",,,"facility","inpatient","1.073490","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOXETINE HCL 20 MG PO CAPS","81000000","CDM","0250","RC","0904-7346-61","NDC",,,"facility","inpatient","1.183006","UN",,"6.08","6.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 250 MG PO TABS","81000000","CDM","0250","RC","0904-7350-06","NDC",,,"facility","inpatient","1.250000","UN",,"9.26","9.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LURASIDONE HCL 20 MG PO TABS","81000000","CDM","0250","RC","0904-7355-04","NDC",,,"facility","inpatient","1.000000","UN",,"13.75","13.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 0.5 MG PO TABS","81000000","CDM","0250","RC","0904-7361-61","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 1 MG PO TABS","81000000","CDM","0250","RC","0904-7362-61","NDC",,,"facility","inpatient","1.088888","UN",,"8.64","8.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MECLIZINE HCL 12.5 MG PO TABS","81000000","CDM","0250","RC","0904-7375-61","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MECLIZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","0904-7376-61","NDC",,,"facility","inpatient","1.186588","UN",,"2.08","2.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG PO TABS","81000000","CDM","0250","RC","0904-7403-61","NDC",,,"facility","inpatient","1.024922","UN",,"1.87","1.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","0904-7427-30","NDC",,,"facility","inpatient","30.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IBUPROFEN 200 MG PO TABS","81000000","CDM","0250","RC","0904-7914-61","NDC",,,"facility","inpatient","2.043478","UN",,"4.60","4.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ULTRABAG/DIANEAL/1.5% DEXTROSE 344 MOSM/L IP SOLN","81000000","CDM","0250","RC","0941-0409-01","NDC",,,"facility","inpatient","7263.157894","ML",,"507","507",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIANEAL LOW CALCIUM/1.5% DEX 344 MOSM/L IP SOLN","81000000","CDM","0250","RC","0941-0409-06","NDC",,,"facility","inpatient","2000.000000","ML",,"260","260",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ULTRABAG/DIANEAL/1.5% DEXTROSE 344 MOSM/L IP SOLN","81000000","CDM","0250","RC","0941-0424-52","NDC",,,"facility","inpatient","2000.000000","ML",,"362.82","362.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ULTRABAG/DIANEAL/2.5% DEXTROSE 395 MOSM/L IP SOLN","81000000","CDM","0250","RC","0941-0430-52","NDC",,,"facility","inpatient","4315.789473","ML",,"329.64","329.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ULTRABAG/DIANEAL/2.5% DEXTROSE 395 MOSM/L IP SOLN","81000000","CDM","0250","RC","0941-0457-01","NDC",,,"facility","inpatient","7230.769230","ML",,"546","546",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ULTRABAG/DIANEAL/2.5% DEXTROSE 395 MOSM/L IP SOLN","81000000","CDM","0250","RC","0941-0457-08","NDC",,,"facility","inpatient","4000.000000","ML",,"286","286",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ULTRABAG/DIANEAL/4.25% DEX 483 MOSM/L IP SOLN","81000000","CDM","0250","RC","0941-0459-01","NDC",,,"facility","inpatient","6000.000000","ML",,"468","468",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EXTRANEAL 7.5 % IP SOLN","81000000","CDM","0250","RC","0941-0679-06","NDC",,,"facility","inpatient","2000.000000","ML",,"915.2","915.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN","81000000","CDM","0250","RC","0942-0641-04","NDC",,,"facility","inpatient","1000.000000","ML",,"78.64","78.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETIC ACID 0.25 % IR SOLN","81000000","CDM","0250","RC","0990-6143-22","NDC",,,"facility","inpatient","250.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MANNITOL 20% IVPB INTERMITTENT SH","81000000","CDM","0250","RC","0990-7715-13","NDC",,,"facility","inpatient","632.450331","ML",,"103.36","103.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYPROMELLOSE 0.5 % OP SOLN","81000000","CDM","0250","RC","0998-0408-15","NDC",,,"facility","inpatient","15.022522","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 0.1 % OP SUSP","81000000","CDM","0250","RC","0998-0615-05","NDC",,,"facility","inpatient","5.000000","ML",,"380.08","380.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM OXIDE -MG SUPPLEMENT 400 (240 MG) MG PO TABS","81000000","CDM","0250","RC","10006-70028","NDC",,,"facility","inpatient","1.032578","UN",,"1.17","1.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SCOPOLAMINE 1 MG/3DAYS TD PT72","81000000","CDM","0250","RC","10019-553-03","NDC",,,"facility","inpatient","1.266666","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SCOPOLAMINE 1 MG/3DAYS TD PT72","81000000","CDM","0250","RC","10019-553-90","NDC",,,"facility","inpatient","1.043010","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PORACTANT ALFA 120 MG/1.5ML TR SUSP","81000000","CDM","0250","RC","10122-510-01","NDC",,,"facility","inpatient","1.511219","ML",,"1266.53","1266.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PORACTANT ALFA 240 MG/3ML TR SUSP","81000000","CDM","0250","RC","10122-510-03","NDC",,,"facility","inpatient","3.627052","ML",,"2834.42","2834.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL/MONONITRATE 100 MG PO TABS - CONSOLIDATED","81000000","CDM","0250","RC","10135-132-01","NDC",,,"facility","inpatient","1.000000","UN",,"2.10","2.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 10 MG PO TABS","81000000","CDM","0250","RC","10135-532-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROBENECID 500 MG PO TABS","81000000","CDM","0250","RC","10135-541-01","NDC",,,"facility","inpatient","1.072727","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHOCARBAMOL 500 MG PO TABS","81000000","CDM","0250","RC","10135-664-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 1 % EX SOLN","81000000","CDM","0250","RC","10135-671-81","NDC",,,"facility","inpatient","10.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 100 MG PO TABS","81000000","CDM","0250","RC","10135-711-01","NDC",,,"facility","inpatient","1.098360","UN",,"10.11","10.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUTAMBEN-TETRACAINE-BENZOCAINE 2-2-14 % EX AERO","81000000","CDM","0250","RC","10223-0201-3","NDC",,,"facility","inpatient","20.000000","GR",,"571.2","571.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SOD BICARB-CITRIC AC-SIMETH 2.21-1.53-0.04 G PO PACK","81000000","CDM","0250","RC","10361-793-01","NDC",,,"facility","inpatient","1.021857","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MONSELS FERRIC SUBSULFATE EX SOLN","81000000","CDM","0250","RC","10481-0112-8","NDC",,,"facility","inpatient","1","EA",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 10.000000 APPLICATION"
"DESMOPRESSIN ACETATE 0.2 MG PO TABS","81000000","CDM","0250","RC","10702-170-01","NDC",,,"facility","inpatient","1.000000","UN",,"41.88","41.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOXINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","10939-50644","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYETHYLENE GLYCOL 3350 17 G PO PACK","81000000","CDM","0250","RC","11523-7268-8","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM POLYSTYRENE SULFONATE PO POWD","81000000","CDM","0250","RC","11534-166-15","NDC",,,"facility","inpatient","15.000000","GR",,"79.05","79.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OFLOXACIN 0.3 % OP SOLN","81000000","CDM","0250","RC","11980-779-05","NDC",,,"facility","inpatient","11.666666","ML",,"10.45","10.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL FILM","81000000","CDM","0250","RC","12496-1202-3","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL FILM","81000000","CDM","0250","RC","12496-1208-3","NDC",,,"facility","inpatient","1.000000","UN",,"50.40","50.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILVER NITRATE-POT NITRATE 75-25 % EX MISC","81000000","CDM","0250","RC","12870-0001-1","NDC",,,"facility","inpatient","1.086956","EA",,"0.90","0.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DONEPEZIL HCL 10 MG PO TABS","81000000","CDM","0250","RC","13668-103-90","NDC",,,"facility","inpatient","6.333333","UN",,"32.14","32.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAZODONE HCL 50 MG PO TABS","81000000","CDM","0250","RC","13668-330-01","NDC",,,"facility","inpatient","1.100628","UN",,"12.54","12.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE ER 100 MG PO TB24","81000000","CDM","0250","RC","13668-341-30","NDC",,,"facility","inpatient","3.666666","UN",,"52.03","52.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IJ SOLN","81000000","CDM","0250","RC","14789-014-01","NDC",,,"facility","inpatient","1.000000","ML",,"77.38","77.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPHEDRINE SULFATE 5 MG/ML INJ (SH)","81000000","CDM","0250","RC","14789-250-07","NDC",,,"facility","inpatient","11.779849","ML",,"96.18","96.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE/EPINEPHRINE/TETRACAINE (L.E.T) TOP SOLN CUSTOM CREATE","81000000","CDM","0250","RC","16500-02005","NDC",,,"facility","inpatient","59.988002","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL 64.8 MG PO TABS","81000000","CDM","0250","RC","16571-667-01","NDC",,,"facility","inpatient","1.000000","UN",,"26.67","26.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL 16.2 MG PO TABS","81000000","CDM","0250","RC","16571-671-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 30 MG PO TABS","81000000","CDM","0250","RC","16714-010-01","NDC",,,"facility","inpatient","1.000000","UN",,"9.07","9.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","81000000","CDM","0250","RC","16714-014-01","NDC",,,"facility","inpatient","1.051200","UN",,"27.79","27.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 500 MG PO TABS","81000000","CDM","0250","RC","16714-035-01","NDC",,,"facility","inpatient","1.132596","UN",,"18.15","18.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 10 MG PO TABS","81000000","CDM","0250","RC","16714-071-04","NDC",,,"facility","inpatient","1.033416","UN",,"14.42","14.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","16714-082-10","NDC",,,"facility","inpatient","1.000000","UN",,"13.73","13.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMFIBROZIL 600 MG PO TABS","81000000","CDM","0250","RC","16714-101-02","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 10 MG PO TABS","81000000","CDM","0250","RC","16714-143-01","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROGESTERONE 100 MG PO CAPS","81000000","CDM","0250","RC","16714-157-01","NDC",,,"facility","inpatient","5.666666","UN",,"15.44","15.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANSOPRAZOLE 30 MG PO TBDD","81000000","CDM","0250","RC","16714-186-02","NDC",,,"facility","inpatient","1.000000","UN",,"63.1","63.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 4 MG PO TBDP","81000000","CDM","0250","RC","16714-200-30","NDC",,,"facility","inpatient","1.333333","UN",,"90.26","90.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN V POTASSIUM 500 MG PO TABS","81000000","CDM","0250","RC","16714-235-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.73","14.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","16714-257-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.08","14.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR","81000000","CDM","0250","RC","16714-293-01","NDC",,,"facility","inpatient","49.997714","ML",,"50.62","50.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR","81000000","CDM","0250","RC","16714-293-02","NDC",,,"facility","inpatient","72.953423","ML",,"44.35","44.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR","81000000","CDM","0250","RC","16714-293-03","NDC",,,"facility","inpatient","113.809276","ML",,"45.07","45.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR","81000000","CDM","0250","RC","16714-294-01","NDC",,,"facility","inpatient","79.756725","ML",,"37.71","37.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS","81000000","CDM","0250","RC","16714-296-01","NDC",,,"facility","inpatient","1.000000","UN",,"20.82","20.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 250 MG PO CAPS","81000000","CDM","0250","RC","16714-298-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 500 MG PO CAPS","81000000","CDM","0250","RC","16714-299-02","NDC",,,"facility","inpatient","1.035242","UN",,"14.71","14.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 500 MG PO CAPS","81000000","CDM","0250","RC","16714-299-03","NDC",,,"facility","inpatient","1.106666","UN",,"12.92","12.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFPODOXIME PROXETIL 100 MG PO TABS","81000000","CDM","0250","RC","16714-394-01","NDC",,,"facility","inpatient","1.000000","UN",,"27.5","27.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFUROXIME AXETIL 500 MG PO TABS","81000000","CDM","0250","RC","16714-401-01","NDC",,,"facility","inpatient","1.000000","UN",,"49.18","49.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENALAPRIL MALEATE 5 MG PO TABS","81000000","CDM","0250","RC","16714-443-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENALAPRIL MALEATE 10 MG PO TABS","81000000","CDM","0250","RC","16714-444-01","NDC",,,"facility","inpatient","5.000000","UN",,"9.48","9.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS","81000000","CDM","0250","RC","16714-477-01","NDC",,,"facility","inpatient","1.101265","UN",,"20.60","20.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR","81000000","CDM","0250","RC","16714-483-02","NDC",,,"facility","inpatient","100.000000","ML",,"35.36","35.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA","81000000","CDM","0250","RC","16714-496-01","NDC",,,"facility","inpatient","15.000000","GR",,"187.43","187.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA","81000000","CDM","0250","RC","16714-496-02","NDC",,,"facility","inpatient","45.000000","GR",,"357.08","357.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 50 MG PO TABS","81000000","CDM","0250","RC","16714-548-01","NDC",,,"facility","inpatient","1.000000","UN",,"46.39","46.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 100 MG PO TABS","81000000","CDM","0250","RC","16714-576-02","NDC",,,"facility","inpatient","1.067653","UN",,"11.75","11.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 20 MG/ML PO CONC","81000000","CDM","0250","RC","16714-601-02","NDC",,,"facility","inpatient","64.222482","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE ER 100 MG PO TB24","81000000","CDM","0250","RC","16714-625-01","NDC",,,"facility","inpatient","1.000000","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE 100 MG/100ML NS (MINIBAG)","81000000","CDM","0250","RC","16714-644-01","NDC",,,"facility","inpatient","1.800000","UN",,"195.78","195.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMVASTATIN 5 MG PO TABS","81000000","CDM","0250","RC","16714-681-02","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 50 MG PO TABS","81000000","CDM","0250","RC","16714-694-01","NDC",,,"facility","inpatient","1.000000","UN",,"27.59","27.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 10MG/ML ORAL SUSP (PEDIATRIC) SH","81000000","CDM","0250","RC","16714-695-01","NDC",,,"facility","inpatient","34.999619","ML",,"24.05","24.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 40 MG/ML PO SUSR","81000000","CDM","0250","RC","16714-696-01","NDC",,,"facility","inpatient","36.057332","ML",,"93.52","93.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RASAGILINE MESYLATE 1 MG PO TABS","81000000","CDM","0250","RC","16714-771-01","NDC",,,"facility","inpatient","1.000000","UN",,"99.96","99.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUMATRIPTAN SUCCINATE 25 MG PO TABS","81000000","CDM","0250","RC","16714-796-01","NDC",,,"facility","inpatient","1.222222","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUMATRIPTAN SUCCINATE 50 MG PO TABS","81000000","CDM","0250","RC","16714-797-01","NDC",,,"facility","inpatient","1.000000","UN",,"99.15","99.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUMATRIPTAN SUCCINATE 100 MG PO TABS","81000000","CDM","0250","RC","16714-798-01","NDC",,,"facility","inpatient","1.146341","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BICALUTAMIDE 50 MG PO TABS","81000000","CDM","0250","RC","16714-816-02","NDC",,,"facility","inpatient","1.000000","UN",,"119.34","119.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS","81000000","CDM","0250","RC","16714-820-01","NDC",,,"facility","inpatient","1.097560","UN",,"109.54","109.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 3 MG PO CPEP","81000000","CDM","0250","RC","16714-829-01","NDC",,,"facility","inpatient","1.000000","UN",,"68.18","68.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERMETHRIN 5 % EX CREA","81000000","CDM","0250","RC","16714-897-01","NDC",,,"facility","inpatient","82.153846","GR",,"5.78","5.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHYTONADIONE 5 MG PO TABS","81000000","CDM","0250","RC","16714-973-02","NDC",,,"facility","inpatient","1.000000","UN",,"1","1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPLERENONE 50 MG PO TABS","81000000","CDM","0250","RC","16729-294-10","NDC",,,"facility","inpatient","1.114285","UN",,"23.08","23.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE ER 500 MG PO CP12","81000000","CDM","0250","RC","16729-331-01","NDC",,,"facility","inpatient","1.000000","UN",,"23.62","23.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10 MG PO TABS","81000000","CDM","0250","RC","16837-87230","NDC",,,"facility","inpatient","1.000000","UN",,"1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE-MENTHOL 20-0.5 % EX AERO","81000000","CDM","0250","RC","16864-68001","NDC",,,"facility","inpatient","79.925925","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE-MENTHOL 20-0.5 % EX AERO","81000000","CDM","0250","RC","16864-68002","NDC",,,"facility","inpatient","67.428571","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUORESCEIN SODIUM 1 MG OP STRP","81000000","CDM","0250","RC","17238-900-11","NDC",,,"facility","inpatient","121.428571","UN",,"47.61","47.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYVINYL ALCOHOL 1.4 % OP SOLN","81000000","CDM","0250","RC","17478-060-12","NDC",,,"facility","inpatient","108.750000","ML",,"14.57","14.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPENTOLATE HCL 1 % OP SOLN","81000000","CDM","0250","RC","17478-100-02","NDC",,,"facility","inpatient","1","EA",,"71.45","71.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 40.000000 DROP"
"PHENYLEPHRINE HCL 2.5 % OP SOLN","81000000","CDM","0250","RC","17478-201-02","NDC",,,"facility","inpatient","2.000000","ML",,"192.93","192.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL 10 % OP SOLN","81000000","CDM","0250","RC","17478-206-05","NDC",,,"facility","inpatient","5.000000","ML",,"168.82","168.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATROPINE SULFATE 1 % OP SOLN","81000000","CDM","0250","RC","17478-215-02","NDC",,,"facility","inpatient","2.000000","ML",,"239.3","239.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATROPINE SULFATE 1 % OP SOLN","81000000","CDM","0250","RC","17478-215-05","NDC",,,"facility","inpatient","6.666666","ML",,"291.9","291.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN-POLYMYXIN B OP OINT","81000000","CDM","0250","RC","17478-238-35","NDC",,,"facility","inpatient","3.500000","GM",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUORESCEIN SODIUM 10 % IV SOLN","81000000","CDM","0250","RC","17478-253-10","NDC",,,"facility","inpatient","5.000000","ML",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPARACAINE HCL 0.5 % OP SOLN","81000000","CDM","0250","RC","17478-263-12","NDC",,,"facility","inpatient","17.743362","ML",,"207.71","207.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUORESCEIN SODIUM 0.6 MG OP STRP","81000000","CDM","0250","RC","17478-403-03","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOCYANINE GREEN 25 MG IV SOLR","81000000","CDM","0250","RC","17478-701-02","NDC",,,"facility","inpatient","37.118297","ME",,"376.31","376.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX GEL","81000000","CDM","0250","RC","17478-711-10","NDC",,,"facility","inpatient","11.153846","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX GEL","81000000","CDM","0250","RC","17478-711-10","NDC",,,"facility","inpatient","5.000000","ML","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MULTIVITAMIN & MINERAL PO LIQD","81000000","CDM","0250","RC","17856-0010-2","NDC",,,"facility","inpatient","16.149825","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE VISCOUS HCL 2 % MT SOLN","81000000","CDM","0250","RC","17856-0138-1","NDC",,,"facility","inpatient","32.551000","ML",,"192.20","192.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN C 500 MG/5ML PO LIQD","81000000","CDM","0250","RC","17856-022-01","NDC",,,"facility","inpatient","5.231788","ML",,"1.55","1.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOPERAMIDE HCL 1 MG/7.5ML PO SOLN","81000000","CDM","0250","RC","17856-0545-1","NDC",,,"facility","inpatient","17.727272","ML",,"22.52","22.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 0.05 MG/ML PO SOLN","81000000","CDM","0250","RC","17856-057-01","NDC",,,"facility","inpatient","2.500000","ML",,"16.87","16.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 200 MG/5ML PO SUSP","81000000","CDM","0250","RC","17856-082-05","NDC",,,"facility","inpatient","5.254716","ML",,"15.67","15.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/ML MT SUSP","81000000","CDM","0250","RC","17856-1045-1","NDC",,,"facility","inpatient","5.229239","ML",,"29.56","29.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 150 MG/15ML PO LIQD","81000000","CDM","0250","RC","17856-116-02","NDC",,,"facility","inpatient","125.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP","81000000","CDM","0250","RC","17856-1286-2","NDC",,,"facility","inpatient","32.474226","ML",,"1.82","1.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 150 MG/15ML PO LIQD","81000000","CDM","0250","RC","17856-1304-1","NDC",,,"facility","inpatient","25.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP","81000000","CDM","0250","RC","17856-1313-3","NDC",,,"facility","inpatient","34.229029","ML",,"1.58","1.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL 20 MG/5ML PO ELIX","81000000","CDM","0250","RC","17856-1508-2","NDC",,,"facility","inpatient","7.500000","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN","81000000","CDM","0250","RC","17856-2002-3","NDC",,,"facility","inpatient","15.402125","ML",,"15.66","15.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML PO ELIX","81000000","CDM","0250","RC","17856-423-04","NDC",,,"facility","inpatient","5.000000","ML",,"52.3","52.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN C 500 MG/5ML PO LIQD","81000000","CDM","0250","RC","17856-842-01","NDC",,,"facility","inpatient","5.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETYLPYRIDINIUM CHLORIDE 0.05 % MT LIQD","81000000","CDM","0250","RC","18029-80111","NDC",,,"facility","inpatient","45.867924","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN C 250 MG PO TABS","81000000","CDM","0250","RC","20555-00100","NDC",,,"facility","inpatient","2.454545","UN",,"1.1","1.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OYSTER SHELL CALCIUM/VITAMIN D 250-3.125 MG-MCG PO TABS","81000000","CDM","0250","RC","20555-02500","NDC",,,"facility","inpatient","1.040322","UN",,"1.30","1.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLECALCIFEROL 25 MCG (1000 UT) PO TABS","81000000","CDM","0250","RC","20555-03300","NDC",,,"facility","inpatient","1.071391","UN",,"1.31","1.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 3 MG PO TABS","81000000","CDM","0250","RC","20555-03600","NDC",,,"facility","inpatient","1.207343","UN",,"1.95","1.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 3 MG PO TABS","81000000","CDM","0250","RC","20555-03601","NDC",,,"facility","inpatient","1.074766","UN",,"1.93","1.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 5 MG PO TABS","81000000","CDM","0250","RC","20555-03901","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZINC SULFATE 220 (50 ZN) MG PO CAPS","81000000","CDM","0250","RC","20555-04000","NDC",,,"facility","inpatient","1.086021","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBETASOL PROPIONATE 0.05 % EX OINT","81000000","CDM","0250","RC","21922-017-04","NDC",,,"facility","inpatient","15.000000","GR",,"596.94","596.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBETASOL PROPIONATE 0.05 % EX OINT","81000000","CDM","0250","RC","21922-017-05","NDC",,,"facility","inpatient","30.000000","GR",,"997.44","997.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX OINT","81000000","CDM","0250","RC","21922-063-15","NDC",,,"facility","inpatient","80.000000","GR",,"66","66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","23155-001-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.12","14.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TETRACYCLINE HCL 250 MG PO CAPS","81000000","CDM","0250","RC","23155-017-01","NDC",,,"facility","inpatient","1.000000","UN",,"31.5","31.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL 80 MG PO TABS","81000000","CDM","0250","RC","23155-026-01","NDC",,,"facility","inpatient","1.222222","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHIMAZOLE 10 MG PO TABS","81000000","CDM","0250","RC","23155-071-01","NDC",,,"facility","inpatient","1.695652","UN",,"13.85","13.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE 10 MG PO CAPS","81000000","CDM","0250","RC","23155-194-01","NDC",,,"facility","inpatient","1.236749","UN",,"14.82","14.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE 20 MG PO CAPS","81000000","CDM","0250","RC","23155-195-01","NDC",,,"facility","inpatient","1.862745","UN",,"14.25","14.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 400 MG PO TABS","81000000","CDM","0250","RC","23155-227-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 800 MG PO TABS","81000000","CDM","0250","RC","23155-228-01","NDC",,,"facility","inpatient","1.000000","UN",,"20.17","20.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","23155-500-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIMODIPINE 30 MG PO CAPS","81000000","CDM","0250","RC","23155-512-30","NDC",,,"facility","inpatient","1.800000","UN",,"57.7","57.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 1 MG PO TABS","81000000","CDM","0250","RC","23155-606-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.22","7.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 200 MG PO TABS","81000000","CDM","0250","RC","23155-724-01","NDC",,,"facility","inpatient","1.086720","UN",,"10.05","10.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERAZOSIN HCL 1 MG PO CAPS","81000000","CDM","0250","RC","23155-735-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.89","10.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERAZOSIN HCL 2 MG PO CAPS","81000000","CDM","0250","RC","23155-736-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERAZOSIN HCL 5 MG PO CAPS","81000000","CDM","0250","RC","23155-737-01","NDC",,,"facility","inpatient","1.000000","UN",,"8.83","8.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","23155-833-01","NDC",,,"facility","inpatient","1.015898","UN",,"8.37","8.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","23155-835-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 125 MG PO CAPS","81000000","CDM","0250","RC","23155-858-78","NDC",,,"facility","inpatient","1.035450","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","23900-01252","NDC",,,"facility","inpatient","16.034482","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN","81000000","CDM","0250","RC","24208-315-10","NDC",,,"facility","inpatient","10.000000","ML",,"67.2","67.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUORESCEIN SODIUM 1 MG OP STRP","81000000","CDM","0250","RC","24208-391-83","NDC",,,"facility","inpatient","1.000000","UN",,"45.38","45.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUORESCEIN SODIUM 1 MG OP STRP","81000000","CDM","0250","RC","24208-391-83","NDC",,,"facility","inpatient","1.000000","EA","RISK","50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"BRIMONIDINE TARTRATE 0.2 % OP SOLN","81000000","CDM","0250","RC","24208-411-05","NDC",,,"facility","inpatient","6.428571","ML",,"90.65","90.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BRIMONIDINE TARTRATE 0.2 % OP SOLN","81000000","CDM","0250","RC","24208-411-10","NDC",,,"facility","inpatient","10.000000","ML",,"170.3","170.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL 2 % OP SOLN","81000000","CDM","0250","RC","24208-485-10","NDC",,,"facility","inpatient","12.000000","ML",,"229.45","229.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN","81000000","CDM","0250","RC","24208-486-10","NDC",,,"facility","inpatient","10.000000","ML",,"337.45","337.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LATANOPROSTENE BUNOD 0.024 % OP SOLN","81000000","CDM","0250","RC","24208-504-05","NDC",,,"facility","inpatient","5.000000","ML",,"39.83","39.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCHOLINE CHLORIDE 20 MG IO SOLR","81000000","CDM","0250","RC","24208-539-20","NDC",,,"facility","inpatient","2.000000","ML",,"432.78","432.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN-POLYMYXIN B OP OINT","81000000","CDM","0250","RC","24208-555-55","NDC",,,"facility","inpatient","3.500000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TROPICAMIDE 1 % OP SOLN","81000000","CDM","0250","RC","24208-585-64","NDC",,,"facility","inpatient","15.000000","ML",,"173.08","173.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TROPICAMIDE 0.5 % OP SOLN","81000000","CDM","0250","RC","24208-590-64","NDC",,,"facility","inpatient","1","EA",,"125.03","125.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 225.000000 DROP"
"NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP","81000000","CDM","0250","RC","24208-635-62","NDC",,,"facility","inpatient","10.000000","ML",,"402.72","402.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN","81000000","CDM","0250","RC","24208-720-02","NDC",,,"facility","inpatient","5.000000","ML",,"323.4","323.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPARACAINE HCL 0.5 % OP SOLN","81000000","CDM","0250","RC","24208-730-06","NDC",,,"facility","inpatient","17.848101","ML",,"196.26","196.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPENTOLATE HCL 1 % OP SOLN","81000000","CDM","0250","RC","24208-735-01","NDC",,,"facility","inpatient","2.272727","ML",,"76.67","76.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT","81000000","CDM","0250","RC","24208-795-35","NDC",,,"facility","inpatient","3.976190","GM",,"89.69","89.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT","81000000","CDM","0250","RC","24208-795-35","NDC",,,"facility","inpatient","3.500000","GM","RISK","99.3","99.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"ERYTHROMYCIN 5 MG/GM OP OINT","81000000","CDM","0250","RC","24208-910-19","NDC",,,"facility","inpatient","1.062363","GR",,"34.52","34.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN 5 MG/GM OP OINT","81000000","CDM","0250","RC","24208-910-55","NDC",,,"facility","inpatient","3.500000","GR",,"89.97","89.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIMODIPINE 6 MG/ML PO SOLN","81000000","CDM","0250","RC","24338-260-10","NDC",,,"facility","inpatient","10.930232","ML",,"352.83","352.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 4 % EX CREA","81000000","CDM","0250","RC","24357-701-06","NDC",,,"facility","inpatient","5.480098","GR",,"2.04","2.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALAMINE 8-8 % EX LOTN","81000000","CDM","0250","RC","24385-413-96","NDC",,,"facility","inpatient","177.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM CITRATE PO SOLN","81000000","CDM","0250","RC","24385-675-10","NDC",,,"facility","inpatient","1480.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETHACRYNIC ACID 25 MG PO TABS","81000000","CDM","0250","RC","25010-215-15","NDC",,,"facility","inpatient","1.000000","UN",,"88.00","88.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 2% GEL UROJET INJ SH","81000000","CDM","0250","RC","25021-673-76","NDC",,,"facility","inpatient","6.446096","ML",,"2.16","2.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 2% GEL UROJET INJ SH","81000000","CDM","0250","RC","25021-673-76","NDC",,,"facility","inpatient","5.999880","ML","PN","10.5","10.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ETOMIDATE 2 MG/ML IV SOLN","81000000","CDM","0250","RC","25021-674-10","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL 10 MG/ML IJ SOLN","81000000","CDM","0250","RC","25021-682-20","NDC",,,"facility","inpatient","3.000000","ML",,"145.5","145.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL 50 MG/ML IJ SOLN","81000000","CDM","0250","RC","25021-683-10","NDC",,,"facility","inpatient","15.333333","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 20 MG PO CPEP","81000000","CDM","0250","RC","27241-097-06","NDC",,,"facility","inpatient","1.000000","UN",,"29.08","29.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 60 MG PO CPEP","81000000","CDM","0250","RC","27241-099-03","NDC",,,"facility","inpatient","1.133333","UN",,"39.26","39.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR","81000000","CDM","0250","RC","27241-139-09","NDC",,,"facility","inpatient","60.000960","ML",,"102.53","102.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALGANCICLOVIR HCL 50 MG/ML PO SOLR","81000000","CDM","0250","RC","27241-159-19","NDC",,,"facility","inpatient","88.000993","ML",,"347.01","347.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FEBUXOSTAT 40 MG PO TABS","81000000","CDM","0250","RC","27808-206-01","NDC",,,"facility","inpatient","1.000000","UN",,"47.60","47.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG/SPRAY TL SOLN","81000000","CDM","0250","RC","28595-120-49","NDC",,,"facility","inpatient","63.700000","GM",,"10.1","10.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG/SPRAY TL SOLN","81000000","CDM","0250","RC","28595-550-49","NDC",,,"facility","inpatient","7.478947","GR",,"1095.01","1095.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METFORMIN HCL ER 500 MG PO TB24","81000000","CDM","0250","RC","29033-055-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALFUZOSIN HCL ER 10 MG PO TB24","81000000","CDM","0250","RC","29300-155-01","NDC",,,"facility","inpatient","1.000000","UN",,"23.18","23.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEMANTINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","29300-171-16","NDC",,,"facility","inpatient","1.494845","UN",,"30.17","30.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 250 MG PO TABS","81000000","CDM","0250","RC","29300-226-01","NDC",,,"facility","inpatient","1.000000","UN",,"11.40","11.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TADALAFIL 20 MG PO TABS","81000000","CDM","0250","RC","29300-289-13","NDC",,,"facility","inpatient","1.000000","UN",,"216.19","216.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 100 MG PO TABS","81000000","CDM","0250","RC","29300-349-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOBENZAPRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","29300-413-01","NDC",,,"facility","inpatient","1.022004","UN",,"11.21","11.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","29300-423-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.40","14.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYETHYLENE GLYCOL 400 0.25 % OP SOLN","81000000","CDM","0250","RC","29943-00215","NDC",,,"facility","inpatient","14.988764","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ITRACONAZOLE 10 MG/ML PO SOLN","81000000","CDM","0250","RC","31722-006-31","NDC",,,"facility","inpatient","176.376436","ML",,"220.18","220.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DROXIDOPA 100 MG PO CAPS","81000000","CDM","0250","RC","31722-014-90","NDC",,,"facility","inpatient","1.000000","UN",,"110.33","110.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DUTASTERIDE 0.5 MG PO CAPS","81000000","CDM","0250","RC","31722-131-30","NDC",,,"facility","inpatient","1.111111","UN",,"33.28","33.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILDENAFIL CITRATE 10 MG/ML PO SUSR","81000000","CDM","0250","RC","31722-136-31","NDC",,,"facility","inpatient","111.982082","ML",,"980.29","980.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEVIRAPINE 200 MG PO TABS","81000000","CDM","0250","RC","31722-505-60","NDC",,,"facility","inpatient","3.000000","UN",,"43.38","43.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","31722-522-01","NDC",,,"facility","inpatient","1.038647","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN 25 MG PO CAPS","81000000","CDM","0250","RC","31722-542-01","NDC",,,"facility","inpatient","1.000000","UN",,"9","9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN 50 MG PO CAPS","81000000","CDM","0250","RC","31722-543-01","NDC",,,"facility","inpatient","1.078431","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN ER 75 MG PO CPCR","81000000","CDM","0250","RC","31722-565-60","NDC",,,"facility","inpatient","1.000000","UN",,"16.52","16.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","31722-569-24","NDC",,,"facility","inpatient","239.997600","ML",,"62.22","62.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MARAVIROC 300 MG PO TABS","81000000","CDM","0250","RC","31722-580-60","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","81000000","CDM","0250","RC","31722-630-31","NDC",,,"facility","inpatient","1.000000","UN",,"56.72","56.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","81000000","CDM","0250","RC","31722-632-31","NDC",,,"facility","inpatient","1.000000","UN",,"61.83","61.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 50 MG PO TABS","81000000","CDM","0250","RC","31722-701-90","NDC",,,"facility","inpatient","1.000000","UN",,"13.26","13.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DONEPEZIL HCL 10 MG PO TABS","81000000","CDM","0250","RC","31722-738-30","NDC",,,"facility","inpatient","1.000000","UN",,"39.94","39.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 400 MG PO TABS","81000000","CDM","0250","RC","31722-777-01","NDC",,,"facility","inpatient","1.046511","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 2 MG PO TABS","81000000","CDM","0250","RC","31722-819-30","NDC",,,"facility","inpatient","1.121212","UN",,"97.90","97.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 20 MG PO TABS","81000000","CDM","0250","RC","31722-829-30","NDC",,,"facility","inpatient","1.500000","UN",,"136.22","136.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 30 MG PO TABS","81000000","CDM","0250","RC","31722-830-30","NDC",,,"facility","inpatient","1.000000","UN",,"136.22","136.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALGANCICLOVIR HCL 50 MG/ML PO SOLR","81000000","CDM","0250","RC","31722-837-10","NDC",,,"facility","inpatient","90.239033","ML",,"378.35","378.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOLVAPTAN 30 MG PO TABS","81000000","CDM","0250","RC","31722-869-03","NDC",,,"facility","inpatient","1.000000","UN",,"1500","1500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBENDAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","31722-935-02","NDC",,,"facility","inpatient","1.000000","UN",,"750","750",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCERIN LIQD","81000000","CDM","0250","RC","31722-939-47","NDC",,,"facility","inpatient","473.882333","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIOGLITAZONE HCL 30 MG PO TABS","81000000","CDM","0250","RC","33342-055-10","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","81000000","CDM","0250","RC","33342-256-66","NDC",,,"facility","inpatient","1.000000","UN",,"56.72","56.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 5 MG PO TABS","81000000","CDM","0250","RC","35046-00393","NDC",,,"facility","inpatient","1.000000","UN",,"1.44","1.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DARUNAVIR 600 MG PO TABS","81000000","CDM","0250","RC","35356-284-60","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","81000000","CDM","0250","RC","35573-428-51","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOCONAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","35573-433-30","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL TARTRATE 5 MG/5ML IV SOLN","81000000","CDM","0250","RC","36000-033-10","NDC",,,"facility","inpatient","5.000000","ML",,"68.75","68.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUMAZENIL 0.5 MG/5ML IV SOLN","81000000","CDM","0250","RC","36000-148-01","NDC",,,"facility","inpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICOTINE POLACRILEX 2 MG MT GUM","81000000","CDM","0250","RC","36800-206-25","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PSYLLIUM VARIABLE DOSE POWDER SF SH","81000000","CDM","0250","RC","37000-02410","NDC",,,"facility","inpatient","1.069306","UN",,"1.66","1.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PSYLLIUM VARIABLE DOSE POWDER SF SH","81000000","CDM","0250","RC","38485-80857","NDC",,,"facility","inpatient","1.092219","UN",,"1.77","1.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CAMPHOR-MENTHOL-METHYL SAL 3-5-15 % EX CREA","81000000","CDM","0250","RC","39278-44020","NDC",,,"facility","inpatient","60.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 4 % EX CREA","81000000","CDM","0250","RC","39328-024-55","NDC",,,"facility","inpatient","5.152091","GR",,"2.43","2.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAKINS (1/4 STRENGTH) 0.125 % EX SOLN","81000000","CDM","0250","RC","39328-064-12","NDC",,,"facility","inpatient","473.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000000","CDM","0250","RC","39822-1000-1","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOMYCIN-POLYMYXIN B GU IR SOLN","81000000","CDM","0250","RC","39822-1201-2","NDC",,,"facility","inpatient","1.000000","ML",,"95.59","95.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CADEXOMER IODINE 0.9 % EX GEL","81000000","CDM","0250","RC","40565-12249","NDC",,,"facility","inpatient","40.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NXSTAGE PUREFLOW RFP 400 DIALYSATE SOLUTION","81000000","CDM","0250","RC","40861-1027-78","NDC",,,"facility","inpatient","5000.000000","ML",,"150.30","150.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NXSTAGE PUREFLOW RFP 401 DIALYSATE SOLUTION","81000000","CDM","0250","RC","40861-1027-92","NDC",,,"facility","inpatient","5065.609622","ML",,"150.45","150.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","41100-81123","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEDIUM CHAIN TRIGLYCERIDES PO OIL","81000000","CDM","0250","RC","41679-36503","NDC",,,"facility","inpatient","953.285578","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEDIUM CHAIN TRIGLYCERIDES PO OIL","81000000","CDM","0250","RC","41679-36513","NDC",,,"facility","inpatient","945.725844","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE HCL (NASAL) 0.1 % NA SOLN","81000000","CDM","0250","RC","42023-103-01","NDC",,,"facility","inpatient","30.000000","ML",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","81000000","CDM","0250","RC","42023-113-10","NDC",,,"facility","inpatient","24.528954","ML",,"124.93","124.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DANTROLENE SODIUM 20 MG IV SOLR","81000000","CDM","0250","RC","42023-123-06","NDC",,,"facility","inpatient","20.000000","ME",,"411.29","411.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN","81000000","CDM","0250","RC","42023-187-10","NDC",,,"facility","inpatient","100.000000","ML",,"624","624",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000000","CDM","0250","RC","42023-201-01","NDC",,,"facility","inpatient","1.000000","UN",,"568.26","568.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN","81000000","CDM","0250","RC","42023-216-25","NDC",,,"facility","inpatient","1.000000","ML",,"151.31","151.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THYROID 15 MG PO TABS","81000000","CDM","0250","RC","42192-327-01","NDC",,,"facility","inpatient","1.121212","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THYROID 30 MG PO TABS","81000000","CDM","0250","RC","42192-329-01","NDC",,,"facility","inpatient","1.000000","UN",,"9.65","9.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THYROID 60 MG PO TABS","81000000","CDM","0250","RC","42192-330-01","NDC",,,"facility","inpatient","1.177777","UN",,"11.82","11.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYOSCYAMINE SULFATE 0.125 MG SL SUBL","81000000","CDM","0250","RC","42192-339-01","NDC",,,"facility","inpatient","1.136147","UN",,"11.90","11.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 250 MG/5ML PO SOLN","81000000","CDM","0250","RC","42192-608-06","NDC",,,"facility","inpatient","6.111606","ML",,"34.70","34.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 250 MG/5ML PO SOLN","81000000","CDM","0250","RC","42192-608-16","NDC",,,"facility","inpatient","470.019767","ML",,"59.21","59.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN 50 MG PR SUPP","81000000","CDM","0250","RC","42211-102-43","NDC",,,"facility","inpatient","2.733333","UN",,"1085.72","1085.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NXSTAGE PUREFLOW RFP 401 DIALYSATE SOLUTION","81000000","CDM","0250","RC","42289-1012-65","NDC",,,"facility","inpatient","5000.000000","ML",,"150.5","150.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERGOCALCIFEROL 1.25 MG (50000 UT) PO CAPS","81000000","CDM","0250","RC","42291-266-01","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOFETILIDE 500 MCG PO CAPS","81000000","CDM","0250","RC","42291-413-60","NDC",,,"facility","inpatient","1.941176","UN",,"47.05","47.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LUBIPROSTONE 24 MCG PO CAPS","81000000","CDM","0250","RC","42291-476-60","NDC",,,"facility","inpatient","1.000000","UN",,"37.09","37.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX PTCH","81000000","CDM","0250","RC","42291-477-11","NDC",,,"facility","inpatient","1.166254","UN",,"50.96","50.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX PTCH","81000000","CDM","0250","RC","42291-495-11","NDC",,,"facility","inpatient","1.222857","UN",,"51.15","51.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 88 MCG PO TABS","81000000","CDM","0250","RC","42292-038-20","NDC",,,"facility","inpatient","1.124256","UN",,"14.81","14.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLCHICINE 0.6 MG PO TABS","81000000","CDM","0250","RC","42292-054-01","NDC",,,"facility","inpatient","1.152173","UN",,"53.04","53.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DANTROLENE SODIUM 250 MG IV SUSR","81000000","CDM","0250","RC","42367-540-32","NDC",,,"facility","inpatient","1.000000","UN",,"5583.13","5583.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL 2 % OP SOLN","81000000","CDM","0250","RC","42571-141-26","NDC",,,"facility","inpatient","11.333333","ML",,"334","334",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN","81000000","CDM","0250","RC","42571-147-26","NDC",,,"facility","inpatient","10.000000","ML",,"488","488",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 250-125 MG PO TABS","81000000","CDM","0250","RC","42571-160-30","NDC",,,"facility","inpatient","1.000000","UN",,"27.5","27.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN HCL 150 MG PO CAPS","81000000","CDM","0250","RC","42571-251-01","NDC",,,"facility","inpatient","1.090909","UN",,"13.27","13.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIOTHYRONINE SODIUM 5 MCG PO TABS","81000000","CDM","0250","RC","42794-018-12","NDC",,,"facility","inpatient","1.000000","UN",,"14.06","14.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OPIUM 10MG/ML (1%) PO TINC SH","81000000","CDM","0250","RC","42799-217-01","NDC",,,"facility","inpatient","117.994100","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IVERMECTIN 3 MG PO TABS","81000000","CDM","0250","RC","42799-806-01","NDC",,,"facility","inpatient","1.100250","UN",,"18.69","18.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESTRADIOL 0.5 MG PO TABS","81000000","CDM","0250","RC","42806-087-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 200 MG/5ML PO SUSR","81000000","CDM","0250","RC","42806-151-34","NDC",,,"facility","inpatient","29.999846","ML",,"47.84","47.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS","81000000","CDM","0250","RC","42806-341-01","NDC",,,"facility","inpatient","1.152380","UN",,"15.88","15.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUINIDINE SULFATE 200 MG PO TABS","81000000","CDM","0250","RC","42806-513-30","NDC",,,"facility","inpatient","1.000000","UN",,"60.35","60.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZONATATE 100 MG PO CAPS","81000000","CDM","0250","RC","42806-714-01","NDC",,,"facility","inpatient","1.038095","UN",,"14.86","14.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 5 MG PO TABS","81000000","CDM","0250","RC","42858-001-10","NDC",,,"facility","inpatient","1.062857","UN",,"25.84","25.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 5 MG PO TABS","81000000","CDM","0250","RC","42858-001-10","NDC",,,"facility","inpatient","1.000000","UN","PN","18.18","18.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE 5 % EX PTCH","81000000","CDM","0250","RC","42858-118-30","NDC",,,"facility","inpatient","1.006182","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 4 MG PO TABS","81000000","CDM","0250","RC","42858-234-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG PO TABS","81000000","CDM","0250","RC","42858-301-01","NDC",,,"facility","inpatient","1.000000","UN",,"29.33","29.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG PO TABS","81000000","CDM","0250","RC","42858-301-25","NDC",,,"facility","inpatient","1.004907","UN",,"22.92","22.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 4 MG PO TABS","81000000","CDM","0250","RC","42858-302-25","NDC",,,"facility","inpatient","1.065058","UN",,"28.18","28.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 8 MG PO TABS","81000000","CDM","0250","RC","42858-303-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE 7.5 MCG/HR TD PTWK","81000000","CDM","0250","RC","42858-353-40","NDC",,,"facility","inpatient","1.000000","UN",,"270.60","270.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL 8 MG SL SUBL","81000000","CDM","0250","RC","42858-502-03","NDC",,,"facility","inpatient","1.666666","UN",,"33.33","33.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE 5 MCG/HR TD PTWK","81000000","CDM","0250","RC","42858-750-40","NDC",,,"facility","inpatient","1.000000","UN",,"193.28","193.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICARDIPINE HCL IN NACL 40-0.83 MG/200ML-% IV SOLN","81000000","CDM","0250","RC","43066-016-10","NDC",,,"facility","inpatient","224.242424","ML",,"1220","1220",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOCINONIDE 0.05 % EX SOLN","81000000","CDM","0250","RC","43386-026-02","NDC",,,"facility","inpatient","46.666666","ML",,"287.9","287.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 40 MG/ML PO SUSR","81000000","CDM","0250","RC","43386-038-60","NDC",,,"facility","inpatient","74.998404","ML",,"453.33","453.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLERGONOVINE MALEATE 0.2 MG PO TABS","81000000","CDM","0250","RC","43386-140-28","NDC",,,"facility","inpatient","1","EA",,"201.57","201.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 5.000000 TAB"
"FLUCYTOSINE 500 MG PO CAPS","81000000","CDM","0250","RC","43386-770-01","NDC",,,"facility","inpatient","1.000000","UN",,"471.83","471.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 0.5 MG PO TABS","81000000","CDM","0250","RC","43547-269-10","NDC",,,"facility","inpatient","1.071428","UN",,"14.95","14.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (SR) 100 MG PO TB12","81000000","CDM","0250","RC","43547-288-10","NDC",,,"facility","inpatient","1.179104","UN",,"12.56","12.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 20 MG PO TABS","81000000","CDM","0250","RC","43547-354-10","NDC",,,"facility","inpatient","1.268907","UN",,"11.76","11.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCHLOROTHIAZIDE 50 MG PO TABS","81000000","CDM","0250","RC","43547-398-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 80 MG PO TABS","81000000","CDM","0250","RC","43547-403-10","NDC",,,"facility","inpatient","1.352941","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 250 MG PO TABS","81000000","CDM","0250","RC","43547-688-10","NDC",,,"facility","inpatient","1.000000","UN",,"24.4","24.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 7.5 MG PO TABS","81000000","CDM","0250","RC","43598-165-30","NDC",,,"facility","inpatient","1.500000","UN",,"56.14","56.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILVER SULFADIAZINE 1 % EX CREA","81000000","CDM","0250","RC","43598-210-40","NDC",,,"facility","inpatient","400.000000","GR",,"318","318",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILVER SULFADIAZINE 1 % EX CREA","81000000","CDM","0250","RC","43598-210-50","NDC",,,"facility","inpatient","50.000000","GR",,"11.45","11.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP","81000000","CDM","0250","RC","43598-326-75","NDC",,,"facility","inpatient","7.500000","ML",,"1076.07","1076.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG SL SUBL","81000000","CDM","0250","RC","43598-436-11","NDC",,,"facility","inpatient","25.000000","UN",,"127","127",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICOTINE 7 MG/24HR TD PT24","81000000","CDM","0250","RC","43598-446-70","NDC",,,"facility","inpatient","1.098490","UN",,"1.33","1.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICOTINE 14 MG/24HR TD PT24","81000000","CDM","0250","RC","43598-447-74","NDC",,,"facility","inpatient","1.107765","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICOTINE 21 MG/24HR TD PT24","81000000","CDM","0250","RC","43598-448-74","NDC",,,"facility","inpatient","1.119241","UN",,"2.07","2.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBENDAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","43598-452-02","NDC",,,"facility","inpatient","1.000000","UN",,"343.36","343.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POSACONAZOLE 100 MG PO TBEC","81000000","CDM","0250","RC","43598-470-60","NDC",,,"facility","inpatient","1.000000","UN",,"222.02","222.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANSOPRAZOLE 30 MG PO TBDD","81000000","CDM","0250","RC","43598-561-78","NDC",,,"facility","inpatient","1.000000","UN",,"59.73","59.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN","81000000","CDM","0250","RC","43598-698-11","NDC",,,"facility","inpatient","1.129032","ML",,"1913.94","1913.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN","81000000","CDM","0250","RC","43598-698-58","NDC",,,"facility","inpatient","1.000000","ML",,"1776.14","1776.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICLOFENAC SODIUM 1 % EX GEL","81000000","CDM","0250","RC","43598-977-10","NDC",,,"facility","inpatient","112.979351","GR",,"72","72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PALIPERIDONE ER 6 MG PO TB24","81000000","CDM","0250","RC","43975-351-03","NDC",,,"facility","inpatient","1.000000","UN",,"58.68","58.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MONSELS FERRIC SUBSULFATE EX SOLN","81000000","CDM","0250","RC","44128-001-08","NDC",,,"facility","inpatient","1","EA",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 8.000000 APPLICATION"
"ACYCLOVIR 5 % EX CREA","81000000","CDM","0250","RC","45802-044-75","NDC",,,"facility","inpatient","5.000000","GR",,"960","960",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX OINT","81000000","CDM","0250","RC","45802-048-35","NDC",,,"facility","inpatient","18.673469","GR",,"87.53","87.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.5 % EX OINT","81000000","CDM","0250","RC","45802-049-35","NDC",,,"facility","inpatient","15.000000","GR",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.025 % EX OINT","81000000","CDM","0250","RC","45802-054-35","NDC",,,"facility","inpatient","15.000000","GR",,"39.78","39.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX OINT","81000000","CDM","0250","RC","45802-055-35","NDC",,,"facility","inpatient","15.000000","GR",,"36.17","36.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX OINT","81000000","CDM","0250","RC","45802-055-36","NDC",,,"facility","inpatient","80.000000","GR",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX CREA","81000000","CDM","0250","RC","45802-059-11","NDC",,,"facility","inpatient","30.000000","GR",,"131.25","131.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX CREA","81000000","CDM","0250","RC","45802-059-35","NDC",,,"facility","inpatient","15.000000","GR",,"87.53","87.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","45802-060-70","NDC",,,"facility","inpatient","1.024691","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","81000000","CDM","0250","RC","45802-064-35","NDC",,,"facility","inpatient","16.200000","GR",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","81000000","CDM","0250","RC","45802-064-36","NDC",,,"facility","inpatient","80.000000","GR",,"61.88","61.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.5 % EX CREA","81000000","CDM","0250","RC","45802-065-35","NDC",,,"facility","inpatient","15.000000","GR",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MUPIROCIN 2 % EX OINT","81000000","CDM","0250","RC","45802-112-22","NDC",,,"facility","inpatient","22.000000","GR",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIPLE ANTIBIOTIC EX OINT","81000000","CDM","0250","RC","45802-143-01","NDC",,,"facility","inpatient","14.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIPLE ANTIBIOTIC EX OINT","81000000","CDM","0250","RC","45802-143-70","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MUSCLE RUB 10-15 % EX CREA","81000000","CDM","0250","RC","45802-174-53","NDC",,,"facility","inpatient","133.571428","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG/SPRAY TL SOLN","81000000","CDM","0250","RC","45802-210-01","NDC",,,"facility","inpatient","5.130588","GR",,"897.88","897.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERMETHRIN 5 % EX CREA","81000000","CDM","0250","RC","45802-269-37","NDC",,,"facility","inpatient","69.600000","GR",,"2.47","2.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 1 % EX OINT","81000000","CDM","0250","RC","45802-276-03","NDC",,,"facility","inpatient","28.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","45802-410-59","NDC",,,"facility","inpatient","30.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 1 % EX CREA","81000000","CDM","0250","RC","45802-434-11","NDC",,,"facility","inpatient","30.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 1 % EX CREA","81000000","CDM","0250","RC","45802-438-03","NDC",,,"facility","inpatient","29.709923","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOCONAZOLE 2 % EX SHAM","81000000","CDM","0250","RC","45802-465-64","NDC",,,"facility","inpatient","120.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 100 MG PO CAPS","81000000","CDM","0250","RC","45802-486-78","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMMONIUM LACTATE 12 % EX LOTN","81000000","CDM","0250","RC","45802-52555","NDC",,,"facility","inpatient","227.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 120 MG PR SUPP","81000000","CDM","0250","RC","45802-732-30","NDC",,,"facility","inpatient","1.000000","UN",,"5.14","5.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 2.5 % EX LOTN","81000000","CDM","0250","RC","45802-937-16","NDC",,,"facility","inpatient","58.999991","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISONIAZID 50 MG/5ML PO SYRP","81000000","CDM","0250","RC","46287-009-01","NDC",,,"facility","inpatient","473.036896","ML",,"129.6","129.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 25 MG/5ML PO SUSP","81000000","CDM","0250","RC","46287-020-01","NDC",,,"facility","inpatient","473.036896","ML",,"109.83","109.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 25 MG/5ML PO SUSP","81000000","CDM","0250","RC","46287-020-04","NDC",,,"facility","inpatient","118.001393","ML",,"211.39","211.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BICALUTAMIDE 50 MG PO TABS","81000000","CDM","0250","RC","47335-485-83","NDC",,,"facility","inpatient","1.000000","UN",,"120.47","120.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VECURONIUM BROMIDE 10 MG IV SOLR","81000000","CDM","0250","RC","47335-931-44","NDC",,,"facility","inpatient","10.000000","ME",,"68.50","68.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL FILM","81000000","CDM","0250","RC","47781-355-11","NDC",,,"facility","inpatient","1.092753","UN",,"35.29","35.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL-NALOXONE HCL 4-1 MG SL FILM","81000000","CDM","0250","RC","47781-356-11","NDC",,,"facility","inpatient","1.000000","UN",,"57.14","57.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL FILM","81000000","CDM","0250","RC","47781-357-11","NDC",,,"facility","inpatient","1.000000","UN",,"53.51","53.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 12 MCG/HR TD PT72","81000000","CDM","0250","RC","47781-423-47","NDC",,,"facility","inpatient","1.000000","UN",,"81.21","81.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 25 MCG/HR TD PT72","81000000","CDM","0250","RC","47781-424-47","NDC",,,"facility","inpatient","5.000000","UN",,"85.06","85.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 50 MCG/HR TD PT72","81000000","CDM","0250","RC","47781-426-47","NDC",,,"facility","inpatient","1.000000","UN",,"116.65","116.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 75 MCG/HR TD PT72","81000000","CDM","0250","RC","47781-427-47","NDC",,,"facility","inpatient","1.000000","UN",,"177.92","177.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","81000000","CDM","0250","RC","47781-468-13","NDC",,,"facility","inpatient","1.000000","UN",,"56.72","56.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","81000000","CDM","0250","RC","47781-470-13","NDC",,,"facility","inpatient","3.000000","UN",,"95.22","95.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN 5 MG/GM OP OINT","81000000","CDM","0250","RC","48102-057-11","NDC",,,"facility","inpatient","1.100783","GR",,"38.22","38.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 250 MG PO CAPS","81000000","CDM","0250","RC","48433-101-01","NDC",,,"facility","inpatient","1.033462","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINERAL OIL PO OIL","81000000","CDM","0250","RC","48433-202-30","NDC",,,"facility","inpatient","34.337349","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SENNOSIDES 8.8 MG/5ML PO SYRP","81000000","CDM","0250","RC","48433-219-05","NDC",,,"facility","inpatient","6.322562","ML",,"1.28","1.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IODINE STRONG 5 % PO SOLN","81000000","CDM","0250","RC","48433-230-15","NDC",,,"facility","inpatient","13.999974","ML",,"2.09","2.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TETRAHYDROZOLINE HCL 0.05 % OP SOLN","81000000","CDM","0250","RC","49348-037-29","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","49348-130-27","NDC",,,"facility","inpatient","30.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROGEN PEROXIDE 3 % EX SOLN","81000000","CDM","0250","RC","49348-179-34","NDC",,,"facility","inpatient","124.051282","ML",,"3.92","3.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT","81000000","CDM","0250","RC","49348-274-72","NDC",,,"facility","inpatient","28.400000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ABACAVIR SULFATE-LAMIVUDINE 600-300 MG PO TABS","81000000","CDM","0250","RC","49702-206-13","NDC",,,"facility","inpatient","1.000000","UN",,"155","155",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOLUTEGRAVIR SODIUM 50 MG PO TABS","81000000","CDM","0250","RC","49702-228-13","NDC",,,"facility","inpatient","1.013698","UN",,"270.59","270.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ABACAVIR-DOLUTEGRAVIR-LAMIVUD 600-50-300 MG PO TABS","81000000","CDM","0250","RC","49702-231-13","NDC",,,"facility","inpatient","1.075471","UN",,"449.7","449.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOLUTEGRAVIR-RILPIVIRINE 50-25 MG PO TABS","81000000","CDM","0250","RC","49702-242-13","NDC",,,"facility","inpatient","1.190476","UN",,"417.25","417.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOLUTEGRAVIR-LAMIVUDINE 50-300 MG PO TABS","81000000","CDM","0250","RC","49702-246-13","NDC",,,"facility","inpatient","1.000000","UN",,"357.2","357.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 30 MG PO TABS","81000000","CDM","0250","RC","49884-009-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.21","7.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 1 MG/5ML PO SOLN","81000000","CDM","0250","RC","49884-042-33","NDC",,,"facility","inpatient","473.031232","ML",,"31.77","31.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 500MCG/ML ORAL SUSP (PEDIATRIC) SH","81000000","CDM","0250","RC","49884-065-01","NDC",,,"facility","inpatient","1.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 0.25 MG PO TBDP","81000000","CDM","0250","RC","49884-110-52","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 0.5 MG PO TBDP","81000000","CDM","0250","RC","49884-111-52","NDC",,,"facility","inpatient","1.000000","UN",,"26.67","26.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINOXIDIL 2.5 MG PO TABS","81000000","CDM","0250","RC","49884-256-01","NDC",,,"facility","inpatient","1.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 0.125 MG PO TBDP","81000000","CDM","0250","RC","49884-306-52","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 0.25 MG PO TBDP","81000000","CDM","0250","RC","49884-307-02","NDC",,,"facility","inpatient","1.000000","UN",,"14.22","14.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 0.25 MG PO TBDP","81000000","CDM","0250","RC","49884-307-52","NDC",,,"facility","inpatient","1.000000","UN",,"31.11","31.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 1 MG PO TBDP","81000000","CDM","0250","RC","49884-315-91","NDC",,,"facility","inpatient","1.888888","UN",,"31.59","31.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 2 MG PO TBDP","81000000","CDM","0250","RC","49884-401-91","NDC",,,"facility","inpatient","1.000000","UN",,"51.37","51.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHIMAZOLE 2.5MG PO PRE-SPLIT TABS SH","81000000","CDM","0250","RC","49884-640-01","NDC",,,"facility","inpatient","0.500000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYUREA 500 MG PO CAPS","81000000","CDM","0250","RC","49884-724-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOLVAPTAN 15 MG PO TABS","81000000","CDM","0250","RC","49884-768-52","NDC",,,"facility","inpatient","1.000000","UN",,"1500","1500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPSONE 100 MG PO TABS","81000000","CDM","0250","RC","49938-101-30","NDC",,,"facility","inpatient","1.000000","UN",,"18.48","18.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPSONE 25 MG PO TABS","81000000","CDM","0250","RC","49938-102-30","NDC",,,"facility","inpatient","1.571428","UN",,"15.06","15.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFDINIR 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","50090-2735-0","NDC",,,"facility","inpatient","60.000000","ML",,"397.44","397.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLURBIPROFEN SODIUM 0.03 % OP SOLN","81000000","CDM","0250","RC","50090-3946-0","NDC",,,"facility","inpatient","2.500000","ML",,"216","216",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","50111-327-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.30","7.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG PO TABS","81000000","CDM","0250","RC","50111-334-01","NDC",,,"facility","inpatient","1.222222","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","50111-397-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAZODONE HCL 50 MG PO TABS","81000000","CDM","0250","RC","50111-560-01","NDC",,,"facility","inpatient","1.057388","UN",,"12.35","12.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAZODONE HCL 100 MG PO TABS","81000000","CDM","0250","RC","50111-561-01","NDC",,,"facility","inpatient","2.000000","UN",,"11.33","11.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOXETINE HCL 20 MG PO CAPS","81000000","CDM","0250","RC","50111-648-01","NDC",,,"facility","inpatient","1.009779","UN",,"14.78","14.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 250 MG PO TABS","81000000","CDM","0250","RC","50111-787-10","NDC",,,"facility","inpatient","1.000000","UN",,"35.03","35.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 250 MG PO TABS","81000000","CDM","0250","RC","50111-787-51","NDC",,,"facility","inpatient","1.000000","UN",,"31.13","31.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 600 MG PO TABS","81000000","CDM","0250","RC","50111-789-10","NDC",,,"facility","inpatient","1.000000","UN",,"56.04","56.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 3% IN NEBU","81000000","CDM","0250","RC","50190-142-63","NDC",,,"facility","inpatient","4.275862","ML",,"1.97","1.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARISOPRODOL 350 MG PO TABS","81000000","CDM","0250","RC","50228-109-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCHLOROTHIAZIDE 12.5 MG PO CAPS","81000000","CDM","0250","RC","50228-146-01","NDC",,,"facility","inpatient","1.045454","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 600 MG PO TABS","81000000","CDM","0250","RC","50228-177-01","NDC",,,"facility","inpatient","1.087912","UN",,"14.45","14.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","50268-037-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 75 MG PO TABS","81000000","CDM","0250","RC","50268-040-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE 250 MG PO TABS","81000000","CDM","0250","RC","50268-054-11","NDC",,,"facility","inpatient","1.000000","UN",,"23.03","23.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 400 MG PO TABS","81000000","CDM","0250","RC","50268-061-15","NDC",,,"facility","inpatient","1.000000","UN",,"20.6","20.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATOVAQUONE 750 MG/5ML PO SUSP","81000000","CDM","0250","RC","50268-086-11","NDC",,,"facility","inpatient","5.069264","ML",,"187.58","187.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATOVAQUONE 750 MG/5ML PO SUSP","81000000","CDM","0250","RC","50268-086-11","NDC",,,"facility","inpatient","5.000000","ML","PN","187.5","187.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ARIPIPRAZOLE 2 MG PO TABS","81000000","CDM","0250","RC","50268-087-12","NDC",,,"facility","inpatient","3.666666","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 5 MG PO TABS","81000000","CDM","0250","RC","50268-088-15","NDC",,,"facility","inpatient","1.133333","UN",,"98.90","98.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 15 MG PO TABS","81000000","CDM","0250","RC","50268-090-12","NDC",,,"facility","inpatient","1.000000","UN",,"88.92","88.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 80 MG PO TABS","81000000","CDM","0250","RC","50268-096-12","NDC",,,"facility","inpatient","1.038095","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 5 MG PO TABS","81000000","CDM","0250","RC","50268-105-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 10 MG PO TABS","81000000","CDM","0250","RC","50268-106-11","NDC",,,"facility","inpatient","1.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENAZEPRIL HCL 10 MG PO TABS","81000000","CDM","0250","RC","50268-110-15","NDC",,,"facility","inpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.5 MG PO TABS","81000000","CDM","0250","RC","50268-130-11","NDC",,,"facility","inpatient","1.000000","UN",,"10.72","10.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 1 MG PO TABS","81000000","CDM","0250","RC","50268-131-11","NDC",,,"facility","inpatient","1.017758","UN",,"10.21","10.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 2 MG PO TABS","81000000","CDM","0250","RC","50268-132-11","NDC",,,"facility","inpatient","1.032894","UN",,"12.07","12.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 300 MG PO TB24","81000000","CDM","0250","RC","50268-141-15","NDC",,,"facility","inpatient","1.000000","UN",,"26.21","26.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CILOSTAZOL 50 MG PO TABS","81000000","CDM","0250","RC","50268-176-15","NDC",,,"facility","inpatient","1.363636","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLARITHROMYCIN 500 MG PO TABS","81000000","CDM","0250","RC","50268-179-13","NDC",,,"facility","inpatient","1.000000","UN",,"38.47","38.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOPIDOGREL BISULFATE 300 MG PO TABS","81000000","CDM","0250","RC","50268-184-11","NDC",,,"facility","inpatient","1.492307","UN",,"69.35","69.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLCHICINE 0.6 MG PO TABS","81000000","CDM","0250","RC","50268-187-11","NDC",,,"facility","inpatient","1.060377","UN",,"37.94","37.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYPROHEPTADINE HCL 4 MG PO TABS","81000000","CDM","0250","RC","50268-189-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOBENZAPRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","50268-190-15","NDC",,,"facility","inpatient","1.255813","UN",,"11.48","11.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE HCL 0.3 MG PO TABS","81000000","CDM","0250","RC","50268-194-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 250 MG PO CAPS","81000000","CDM","0250","RC","50268-268-15","NDC",,,"facility","inpatient","1.034052","UN",,"2.00","2.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE HYCLATE 100 MG PO CAPS","81000000","CDM","0250","RC","50268-278-15","NDC",,,"facility","inpatient","1.040449","UN",,"21.99","21.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERGOCALCIFEROL 1.25 MG (50000 UT) PO CAPS","81000000","CDM","0250","RC","50268-297-11","NDC",,,"facility","inpatient","1.043478","UN",,"1.95","1.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EZETIMIBE 10 MG PO TABS","81000000","CDM","0250","RC","50268-298-12","NDC",,,"facility","inpatient","1.096969","UN",,"54.45","54.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCYTOSINE 500 MG PO CAPS","81000000","CDM","0250","RC","50268-332-11","NDC",,,"facility","inpatient","1.000000","UN",,"513.73","513.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERROUS SULFATE 300 (60 FE) MG/5ML PO SOLN","81000000","CDM","0250","RC","50268-336-24","NDC",,,"facility","inpatient","5.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMFIBROZIL 600 MG PO TABS","81000000","CDM","0250","RC","50268-350-15","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLIPIZIDE 10 MG PO TABS","81000000","CDM","0250","RC","50268-362-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS","81000000","CDM","0250","RC","50268-402-15","NDC",,,"facility","inpatient","1.105263","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 5 MG PO TABS","81000000","CDM","0250","RC","50268-405-11","NDC",,,"facility","inpatient","1.000000","UN",,"9.79","9.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN 25 MG PO CAPS","81000000","CDM","0250","RC","50268-430-15","NDC",,,"facility","inpatient","1.049751","UN",,"8.82","8.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN 50 MG PO CAPS","81000000","CDM","0250","RC","50268-431-15","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 5 MG PO TABS","81000000","CDM","0250","RC","50268-447-15","NDC",,,"facility","inpatient","1.000000","UN",,"9.91","9.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 10 MG PO TABS","81000000","CDM","0250","RC","50268-448-15","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 100 MG/ML PO SOLN","81000000","CDM","0250","RC","50268-470-11","NDC",,,"facility","inpatient","5.000000","ML",,"27.5","27.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LETROZOLE 2.5 MG PO TABS","81000000","CDM","0250","RC","50268-476-11","NDC",,,"facility","inpatient","1.000000","UN",,"117.34","117.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 25 MG PO TABS","81000000","CDM","0250","RC","50268-504-11","NDC",,,"facility","inpatient","1.224855","UN",,"11.58","11.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MECLIZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","50268-523-15","NDC",,,"facility","inpatient","1.114942","UN",,"1.89","1.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 3 MG PO TABS","81000000","CDM","0250","RC","50268-524-11","NDC",,,"facility","inpatient","1.079164","UN",,"1.94","1.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELOXICAM 15 MG PO TABS","81000000","CDM","0250","RC","50268-526-15","NDC",,,"facility","inpatient","1.000000","UN",,"22.37","22.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 25 MG PO TB24","81000000","CDM","0250","RC","50268-540-15","NDC",,,"facility","inpatient","1.092896","UN",,"11.83","11.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 50 MG PO TB24","81000000","CDM","0250","RC","50268-541-15","NDC",,,"facility","inpatient","1.128309","UN",,"10.49","10.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MUPIROCIN 2 % EX OINT","81000000","CDM","0250","RC","50268-568-11","NDC",,,"facility","inpatient","1.030374","GR",,"33.32","33.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MUPIROCIN 2 % EX OINT","81000000","CDM","0250","RC","50268-568-15","NDC",,,"facility","inpatient","1.000000","GR",,"33.32","33.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MUPIROCIN 2 % EX OINT","81000000","CDM","0250","RC","50268-572-60","NDC",,,"facility","inpatient","1","EA",,"33.32","33.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 1.000000 APPLICATION"
"MONTELUKAST SODIUM 5 MG PO CHEW","81000000","CDM","0250","RC","50268-574-15","NDC",,,"facility","inpatient","1.000000","UN",,"22.58","22.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MOXIFLOXACIN HCL 400 MG PO TABS","81000000","CDM","0250","RC","50268-576-13","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG PO TBCR","81000000","CDM","0250","RC","50268-584-13","NDC",,,"facility","inpatient","9.000000","UN",,"1","1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","81000000","CDM","0250","RC","50268-585-11","NDC",,,"facility","inpatient","1.114537","UN",,"21.92","21.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAPROXEN 250 MG PO TABS","81000000","CDM","0250","RC","50268-594-15","NDC",,,"facility","inpatient","1.333333","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAPROXEN 375 MG PO TABS","81000000","CDM","0250","RC","50268-595-15","NDC",,,"facility","inpatient","1.375002","UN",,"1.67","1.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24","81000000","CDM","0250","RC","50268-597-15","NDC",,,"facility","inpatient","1.017003","UN",,"10.52","10.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE ER OSMOTIC RELEASE 60 MG PO TB24","81000000","CDM","0250","RC","50268-598-15","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE ER OSMOTIC RELEASE 90 MG PO TB24","81000000","CDM","0250","RC","50268-599-15","NDC",,,"facility","inpatient","1.307692","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORTRIPTYLINE HCL 50 MG PO CAPS","81000000","CDM","0250","RC","50268-605-15","NDC",,,"facility","inpatient","1.022727","UN",,"10.57","10.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUETIAPINE FUMARATE 100 MG PO TABS","81000000","CDM","0250","RC","50268-632-15","NDC",,,"facility","inpatient","1.185022","UN",,"32.43","32.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUETIAPINE FUMARATE 200 MG PO TABS","81000000","CDM","0250","RC","50268-633-15","NDC",,,"facility","inpatient","1.016520","UN",,"46.87","46.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","81000000","CDM","0250","RC","50268-639-15","NDC",,,"facility","inpatient","1.000000","UN",,"22.15","22.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PAROXETINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","50268-640-15","NDC",,,"facility","inpatient","1.326530","UN",,"12.95","12.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 10 MG PO TABS","81000000","CDM","0250","RC","50268-662-11","NDC",,,"facility","inpatient","1.273291","UN",,"13.65","13.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAVASTATIN SODIUM 20 MG PO TABS","81000000","CDM","0250","RC","50268-666-11","NDC",,,"facility","inpatient","1.000000","UN",,"14.36","14.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYVINYL ALCOHOL 1.4 % OP SOLN","81000000","CDM","0250","RC","50268-678-15","NDC",,,"facility","inpatient","17.118244","ML",,"2.03","2.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRIMIDONE 50 MG PO TABS","81000000","CDM","0250","RC","50268-686-15","NDC",,,"facility","inpatient","1.000000","UN",,"9.15","9.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRIMIDONE 250 MG PO TABS","81000000","CDM","0250","RC","50268-687-15","NDC",,,"facility","inpatient","1.000000","UN",,"13.8","13.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROSUVASTATIN CALCIUM 10 MG PO TABS","81000000","CDM","0250","RC","50268-709-15","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 800 MG PO TABS","81000000","CDM","0250","RC","50268-720-15","NDC",,,"facility","inpatient","1.317757","UN",,"43.44","43.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SOTALOL HCL 80 MG PO TABS","81000000","CDM","0250","RC","50268-724-11","NDC",,,"facility","inpatient","1.000000","UN",,"10.26","10.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SOTALOL HCL 120 MG PO TABS","81000000","CDM","0250","RC","50268-725-11","NDC",,,"facility","inpatient","1.000000","UN",,"19.05","19.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS","81000000","CDM","0250","RC","50268-728-15","NDC",,,"facility","inpatient","1.018126","UN",,"14.86","14.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 0.5 MG PO TABS","81000000","CDM","0250","RC","50268-742-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 2 MG PO TABS","81000000","CDM","0250","RC","50268-744-11","NDC",,,"facility","inpatient","1.000000","UN",,"4.47","4.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TORSEMIDE 20 MG PO TABS","81000000","CDM","0250","RC","50268-756-15","NDC",,,"facility","inpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TORSEMIDE 100 MG PO TABS","81000000","CDM","0250","RC","50268-757-15","NDC",,,"facility","inpatient","1.000000","UN",,"15.92","15.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TIZANIDINE HCL 2 MG PO TABS","81000000","CDM","0250","RC","50268-759-15","NDC",,,"facility","inpatient","1.000000","UN",,"14.78","14.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TIZANIDINE HCL 4 MG PO TABS","81000000","CDM","0250","RC","50268-760-15","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERAZOSIN HCL 1 MG PO CAPS","81000000","CDM","0250","RC","50268-764-11","NDC",,,"facility","inpatient","1.285714","UN",,"10.38","10.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERAZOSIN HCL 2 MG PO CAPS","81000000","CDM","0250","RC","50268-765-11","NDC",,,"facility","inpatient","1.062500","UN",,"13.12","13.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERAZOSIN HCL 5 MG PO CAPS","81000000","CDM","0250","RC","50268-766-11","NDC",,,"facility","inpatient","1.029197","UN",,"11.48","11.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TEMAZEPAM 15 MG PO CAPS","81000000","CDM","0250","RC","50268-779-11","NDC",,,"facility","inpatient","1.000000","UN",,"20","20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALGANCICLOVIR HCL 450 MG PO TABS","81000000","CDM","0250","RC","50268-787-12","NDC",,,"facility","inpatient","1.016194","UN",,"448.28","448.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALACYCLOVIR HCL 500 MG PO TABS","81000000","CDM","0250","RC","50268-788-15","NDC",,,"facility","inpatient","1.212389","UN",,"30.13","30.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL/MONONITRATE 100 MG PO TABS - CONSOLIDATED","81000000","CDM","0250","RC","50268-851-11","NDC",,,"facility","inpatient","1.073924","UN",,"1.94","1.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 100 MCG PO TABS","81000000","CDM","0250","RC","50268-852-11","NDC",,,"facility","inpatient","1.034632","UN",,"1.12","1.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG PO TABS","81000000","CDM","0250","RC","50268-855-11","NDC",,,"facility","inpatient","1.060085","UN",,"1.98","1.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOXINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","50268-859-11","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN C 250 MG PO TABS","81000000","CDM","0250","RC","50268-860-11","NDC",,,"facility","inpatient","1.413793","UN",,"0.95","0.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLECALCIFEROL 10 MCG (400 UNIT) PO TABS","81000000","CDM","0250","RC","50268-863-11","NDC",,,"facility","inpatient","1.034722","UN",,"1.47","1.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN","81000000","CDM","0250","RC","50383-233-10","NDC",,,"facility","inpatient","10.000000","ML",,"490.4","490.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 25 MG/ML PO SOLN","81000000","CDM","0250","RC","50383-286-04","NDC",,,"facility","inpatient","100.000000","ML",,"209.4","209.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 250 MG/5ML PO SOLN","81000000","CDM","0250","RC","50383-311-09","NDC",,,"facility","inpatient","6.000007","ML",,"12.87","12.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN","81000000","CDM","0250","RC","50383-627-50","NDC",,,"facility","inpatient","50.912597","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL CONTINUOUS NEB SIMPLE SH","81000000","CDM","0250","RC","50383-741-20","NDC",,,"facility","inpatient","20.000000","ML",,"173.88","173.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE VISCOUS HCL 2 % MT SOLN","81000000","CDM","0250","RC","50383-775-04","NDC",,,"facility","inpatient","100.000000","ML",,"66","66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE VISCOUS HCL 2 % MT SOLN","81000000","CDM","0250","RC","50383-775-17","NDC",,,"facility","inpatient","14.999956","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMETHICONE 40 MG/0.6ML PO SUSP","81000000","CDM","0250","RC","50383-785-30","NDC",,,"facility","inpatient","31.768913","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLECALCIFEROL 10 MCG/ML PO LIQD","81000000","CDM","0250","RC","50383-917-50","NDC",,,"facility","inpatient","50.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 500 MG/5ML (10%) PO SUSR","81000000","CDM","0250","RC","50419-773-01","NDC",,,"facility","inpatient","100.000000","ML",,"35.51","35.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 250 MG/5ML (5%) PO SUSR","81000000","CDM","0250","RC","50419-777-01","NDC",,,"facility","inpatient","113.333333","ML",,"78.25","78.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ITRACONAZOLE 100 MG PO CAPS","81000000","CDM","0250","RC","50458-290-01","NDC",,,"facility","inpatient","1.000000","UN",,"101.32","101.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 1 MG PO TABS","81000000","CDM","0250","RC","50458-300-06","NDC",,,"facility","inpatient","2.800000","UN",,"48","48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 3 MG PO TABS","81000000","CDM","0250","RC","50458-330-06","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIVAROXABAN 2.5 MG PO TABS","81000000","CDM","0250","RC","50458-577-10","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIVAROXABAN 15 MG PO TABS","81000000","CDM","0250","RC","50458-578-10","NDC",,,"facility","inpatient","1.195121","UN",,"89.42","89.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIVAROXABAN 20 MG PO TABS","81000000","CDM","0250","RC","50458-579-10","NDC",,,"facility","inpatient","1.063532","UN",,"89.39","89.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIVAROXABAN 10 MG PO TABS","81000000","CDM","0250","RC","50458-580-10","NDC",,,"facility","inpatient","1.000000","UN",,"54.81","54.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 250 MG PO TABS","81000000","CDM","0250","RC","50474-594-40","NDC",,,"facility","inpatient","1.000000","UN",,"33.33","33.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 500 MG PO TABS","81000000","CDM","0250","RC","50474-595-40","NDC",,,"facility","inpatient","1.000000","UN",,"51.20","51.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLLAGENASE 250 UNIT/GM EX OINT","81000000","CDM","0250","RC","50484-010-30","NDC",,,"facility","inpatient","30.000000","GR",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE 10 % MT GEL","81000000","CDM","0250","RC","50486-55032","NDC",,,"facility","inpatient","6.999941","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEXILETINE HCL 150 MG PO CAPS","81000000","CDM","0250","RC","50742-239-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.44","14.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24","81000000","CDM","0250","RC","50742-248-30","NDC",,,"facility","inpatient","1.452830","UN",,"14.12","14.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL FILM","81000000","CDM","0250","RC","50742-364-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE 10 MCG/HR TD PTWK","81000000","CDM","0250","RC","50742-374-01","NDC",,,"facility","inpatient","5.000000","UN",,"374.6","374.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SCOPOLAMINE 1 MG/3DAYS TD PT72","81000000","CDM","0250","RC","50742-505-04","NDC",,,"facility","inpatient","1.208695","UN",,"91.9","91.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MOUTH KOTE MT SOLN","81000000","CDM","0250","RC","50930-09802","NDC",,,"facility","inpatient","67.428571","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOLAZONE 2.5 MG PO TABS","81000000","CDM","0250","RC","51079-023-20","NDC",,,"facility","inpatient","1.148148","UN",,"18.1","18.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOLAZONE 5 MG PO TABS","81000000","CDM","0250","RC","51079-024-20","NDC",,,"facility","inpatient","1.012924","UN",,"19.60","19.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","81000000","CDM","0250","RC","51079-051-20","NDC",,,"facility","inpatient","1.000000","UN",,"28.97","28.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORTHALIDONE 25 MG PO TABS","81000000","CDM","0250","RC","51079-058-20","NDC",,,"facility","inpatient","1.049382","UN",,"14.41","14.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 20 MG PO TABS","81000000","CDM","0250","RC","51079-072-20","NDC",,,"facility","inpatient","1.000000","UN",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","51079-074-20","NDC",,,"facility","inpatient","1.051880","UN",,"10.46","10.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","51079-075-20","NDC",,,"facility","inpatient","1.083333","UN",,"7.27","7.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","51079-076-20","NDC",,,"facility","inpatient","1.029602","UN",,"13.38","13.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISONIAZID 300 MG PO TABS","81000000","CDM","0250","RC","51079-083-20","NDC",,,"facility","inpatient","1.016666","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 12.5MG PO PRE-SPLIT TABS SH","81000000","CDM","0250","RC","51079-103-20","NDC",,,"facility","inpatient","0.510914","UN",,"14.71","14.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","51079-118-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 20 MG PO TABS","81000000","CDM","0250","RC","51079-119-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","51079-131-20","NDC",,,"facility","inpatient","1.000000","UN",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORDIAZEPOXIDE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","51079-141-20","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 100 MG PO TABS","81000000","CDM","0250","RC","51079-205-20","NDC",,,"facility","inpatient","1.044364","UN",,"10.34","10.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 300 MG PO TABS","81000000","CDM","0250","RC","51079-206-20","NDC",,,"facility","inpatient","1.038523","UN",,"14.85","14.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL TARTRATE 25 MG PO TABS","81000000","CDM","0250","RC","51079-255-20","NDC",,,"facility","inpatient","1.068940","UN",,"14.11","14.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIAZEPAM 2 MG PO TABS","81000000","CDM","0250","RC","51079-284-20","NDC",,,"facility","inpatient","1.049036","UN",,"36.12","36.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIAZEPAM 5 MG PO TABS","81000000","CDM","0250","RC","51079-285-20","NDC",,,"facility","inpatient","1.126865","UN",,"29.64","29.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIAZEPAM 10 MG PO TABS","81000000","CDM","0250","RC","51079-286-20","NDC",,,"facility","inpatient","1.030303","UN",,"38.28","38.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORDIAZEPOXIDE HCL 5 MG PO CAPS","81000000","CDM","0250","RC","51079-374-20","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORDIAZEPOXIDE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","51079-375-20","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXEPIN HCL 10 MG PO CAPS","81000000","CDM","0250","RC","51079-436-20","NDC",,,"facility","inpatient","1.114285","UN",,"14.67","14.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXEPIN HCL 25 MG PO CAPS","81000000","CDM","0250","RC","51079-437-20","NDC",,,"facility","inpatient","1.000000","UN",,"10.85","10.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXEPIN HCL 50 MG PO CAPS","81000000","CDM","0250","RC","51079-438-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 125 MCG PO TABS","81000000","CDM","0250","RC","51079-443-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 25 MCG PO TABS","81000000","CDM","0250","RC","51079-444-20","NDC",,,"facility","inpatient","1.063593","UN",,"7.50","7.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 150 MCG PO TABS","81000000","CDM","0250","RC","51079-445-20","NDC",,,"facility","inpatient","1.038929","UN",,"14.85","14.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORPROMAZINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","51079-516-20","NDC",,,"facility","inpatient","1.000000","UN",,"88.95","88.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 80 MG PO TABS","81000000","CDM","0250","RC","51079-527-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","51079-563-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETIRIZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","51079-597-20","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAZOSIN HCL 1 MG PO CAPS","81000000","CDM","0250","RC","51079-630-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAZOSIN HCL 2 MG PO CAPS","81000000","CDM","0250","RC","51079-631-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAZOSIN HCL 5 MG PO CAPS","81000000","CDM","0250","RC","51079-632-20","NDC",,,"facility","inpatient","1.000000","UN",,"23.69","23.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATENOLOL 50 MG PO TABS","81000000","CDM","0250","RC","51079-684-20","NDC",,,"facility","inpatient","1.333333","UN",,"14.26","14.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATENOLOL 100 MG PO TABS","81000000","CDM","0250","RC","51079-685-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOPERAMIDE HCL 2 MG PO CAPS","81000000","CDM","0250","RC","51079-690-20","NDC",,,"facility","inpatient","1.226415","UN",,"1.66","1.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HALOPERIDOL 0.5 MG PO TABS","81000000","CDM","0250","RC","51079-733-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HALOPERIDOL 1 MG PO TABS","81000000","CDM","0250","RC","51079-734-20","NDC",,,"facility","inpatient","1.076190","UN",,"14.53","14.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HALOPERIDOL 2 MG PO TABS","81000000","CDM","0250","RC","51079-735-20","NDC",,,"facility","inpatient","1.000000","UN",,"12.69","12.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HALOPERIDOL 5 MG PO TABS","81000000","CDM","0250","RC","51079-736-20","NDC",,,"facility","inpatient","1.000000","UN",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL 30 MG PO TABS","81000000","CDM","0250","RC","51079-745-20","NDC",,,"facility","inpatient","5.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL 60 MG PO TABS","81000000","CDM","0250","RC","51079-746-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCRALFATE 1 G PO TABS","81000000","CDM","0250","RC","51079-753-20","NDC",,,"facility","inpatient","1.021276","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL TARTRATE 50 MG PO TABS","81000000","CDM","0250","RC","51079-801-20","NDC",,,"facility","inpatient","1.091295","UN",,"12.65","12.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NADOLOL 20 MG PO TABS","81000000","CDM","0250","RC","51079-812-20","NDC",,,"facility","inpatient","1.000000","UN",,"34.05","34.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 500 MG PO TABS","81000000","CDM","0250","RC","51079-821-20","NDC",,,"facility","inpatient","1.035955","UN",,"18.06","18.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 5 MG PO TABS","81000000","CDM","0250","RC","51079-886-20","NDC",,,"facility","inpatient","1.027397","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 10 MG PO TABS","81000000","CDM","0250","RC","51079-888-20","NDC",,,"facility","inpatient","1.224899","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOZAPINE 100 MG PO TABS","81000000","CDM","0250","RC","51079-922-20","NDC",,,"facility","inpatient","1.000000","UN",,"18.33","18.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR","81000000","CDM","0250","RC","51079-923-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 25MG PO PRE-SPLIT TABS SH","81000000","CDM","0250","RC","51079-928-20","NDC",,,"facility","inpatient","0.250000","UN",,"0.83","0.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 200 MG PO TABS","81000000","CDM","0250","RC","51079-929-20","NDC",,,"facility","inpatient","1.307692","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 12.5 MG PO TABS","81000000","CDM","0250","RC","51079-931-20","NDC",,,"facility","inpatient","1.038216","UN",,"13.28","13.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 25 MG PO TABS","81000000","CDM","0250","RC","51079-932-20","NDC",,,"facility","inpatient","1.079207","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL 75 MG PO TABS","81000000","CDM","0250","RC","51079-943-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL 100 MG PO TABS","81000000","CDM","0250","RC","51079-944-20","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXAZOSIN MESYLATE 1 MG PO TABS","81000000","CDM","0250","RC","51079-957-20","NDC",,,"facility","inpatient","1.057142","UN",,"19.42","19.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXAZOSIN MESYLATE 2 MG PO TABS","81000000","CDM","0250","RC","51079-958-20","NDC",,,"facility","inpatient","1.055172","UN",,"18.58","18.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 20 MG PO TABS","81000000","CDM","0250","RC","51079-966-20","NDC",,,"facility","inpatient","1.179775","UN",,"1.87","1.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 50 MG PO TABS","81000000","CDM","0250","RC","51079-979-20","NDC",,,"facility","inpatient","1.000000","UN",,"13.33","13.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUSPIRONE HCL 5 MG PO TABS","81000000","CDM","0250","RC","51079-985-20","NDC",,,"facility","inpatient","1.012012","UN",,"10.22","10.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUSPIRONE HCL 10 MG PO TABS","81000000","CDM","0250","RC","51079-986-20","NDC",,,"facility","inpatient","1.024169","UN",,"13.13","13.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENAZOPYRIDINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","51293-801-01","NDC",,,"facility","inpatient","1.000000","UN",,"1.33","1.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE-MENTHOL 20-0.5 % EX AERO","81000000","CDM","0250","RC","51409-00722","NDC",,,"facility","inpatient","78.347632","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETIC ACID 3 % SOLN","81000000","CDM","0250","RC","51552-051-06","NDC",,,"facility","inpatient","500.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETIRIZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","51660-939-01","NDC",,,"facility","inpatient","1.029197","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE","81000000","CDM","0250","RC","51672-1267-5","NDC",,,"facility","inpatient","5.000000","GR",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOCINONIDE 0.05 % EX SOLN","81000000","CDM","0250","RC","51672-1273-2","NDC",,,"facility","inpatient","20.000000","ML",,"287.9","287.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 1 % EX CREA","81000000","CDM","0250","RC","51672-1275-1","NDC",,,"facility","inpatient","15.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOCONAZOLE 2 % EX CREA","81000000","CDM","0250","RC","51672-1298-1","NDC",,,"facility","inpatient","15.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICONAZOLE NITRATE 2 % EX CREA","81000000","CDM","0250","RC","51672-2001-1","NDC",,,"facility","inpatient","15.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 1 % EX CREA","81000000","CDM","0250","RC","51672-2002-1","NDC",,,"facility","inpatient","15.779220","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 1 % EX CREA","81000000","CDM","0250","RC","51672-2002-2","NDC",,,"facility","inpatient","30.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 1 % VA CREA","81000000","CDM","0250","RC","51672-2003-6","NDC",,,"facility","inpatient","45.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 0.5 % EX CREA","81000000","CDM","0250","RC","51672-2010-2","NDC",,,"facility","inpatient","30.543396","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","51672-2030-3","NDC",,,"facility","inpatient","32.926829","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE 1 % EX SOLN","81000000","CDM","0250","RC","51672-2037-1","NDC",,,"facility","inpatient","10.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN ZINC 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","51672-2075-1","NDC",,,"facility","inpatient","17.368280","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN ZINC 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","51672-2075-2","NDC",,,"facility","inpatient","28.400000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETIRIZINE HCL 1 MG/ML PO SOLN","81000000","CDM","0250","RC","51672-2102-8","NDC",,,"facility","inpatient","119.990400","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORATADINE 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","51672-2131-8","NDC",,,"facility","inpatient","119.992735","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX OINT","81000000","CDM","0250","RC","51672-3020-9","NDC",,,"facility","inpatient","35.440000","GR",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORTRIPTYLINE HCL 75 MG PO CAPS","81000000","CDM","0250","RC","51672-4004-1","NDC",,,"facility","inpatient","1.000000","UN",,"23.2","23.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBAMAZEPINE 200 MG PO TABS","81000000","CDM","0250","RC","51672-4005-1","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE 125 MG PO TABS","81000000","CDM","0250","RC","51672-4022-1","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"WARFARIN SODIUM 2.5 MG PO TABS","81000000","CDM","0250","RC","51672-4029-1","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENALAPRIL MALEATE 5 MG PO TABS","81000000","CDM","0250","RC","51672-4038-1","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA","81000000","CDM","0250","RC","51672-4048-1","NDC",,,"facility","inpatient","15.000000","GR",,"153.6","153.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETIRIZINE HCL 1 MG/ML PO SOLN","81000000","CDM","0250","RC","51672-4070-8","NDC",,,"facility","inpatient","119.990400","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROPRUSSIDE SODIUM-NACL 50-0.9 MG/100ML-% IV SOLN","81000000","CDM","0250","RC","51754-1006-1","NDC",,,"facility","inpatient","168.571428","ML",,"429","429",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM ACETATE 2 MEQ/ML IV SOLN","81000000","CDM","0250","RC","51754-2001-4","NDC",,,"facility","inpatient","28.822718","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","51754-5001-1","NDC",,,"facility","inpatient","53.175716","ML",,"72.10","72.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","51754-5011-1","NDC",,,"facility","inpatient","12.222222","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 4.2 % IV SOLN","81000000","CDM","0250","RC","51754-5012-4","NDC",,,"facility","inpatient","10.000000","ML",,"57.72","57.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM BICARB-CITRIC ACID 20 MEQ PO TBEF","81000000","CDM","0250","RC","51801-011-30","NDC",,,"facility","inpatient","1.134759","UN",,"9.24","9.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM BICARB-CITRIC ACID 20 MEQ PO TBEF","81000000","CDM","0250","RC","51801-012-01","NDC",,,"facility","inpatient","1.104809","UN",,"8.84","8.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM BICARB-CITRIC ACID 10 MEQ PO TBEF","81000000","CDM","0250","RC","51801-013-30","NDC",,,"facility","inpatient","1.231446","UN",,"13.25","13.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM BICARB-CITRIC ACID 10 MEQ PO TBEF","81000000","CDM","0250","RC","51801-014-30","NDC",,,"facility","inpatient","1.099272","UN",,"12.70","12.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE 0.1 MG/24HR TD PTWK","81000000","CDM","0250","RC","51862-453-04","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE 0.2 MG/24HR TD PTWK","81000000","CDM","0250","RC","51862-454-04","NDC",,,"facility","inpatient","1.266666","UN",,"167.48","167.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESVENLAFAXINE SUCCINATE ER 50 MG PO TB24","81000000","CDM","0250","RC","51991-311-33","NDC",,,"facility","inpatient","1.000000","UN",,"47.53","47.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETIRIZINE HCL 1 MG/ML PO SOLN","81000000","CDM","0250","RC","51991-837-04","NDC",,,"facility","inpatient","120.019203","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPLERENONE 50 MG PO TABS","81000000","CDM","0250","RC","51991-878-33","NDC",,,"facility","inpatient","2.200000","UN",,"22.91","22.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TETRACYCLINE HCL 250 MG PO CAPS","81000000","CDM","0250","RC","51991-906-01","NDC",,,"facility","inpatient","1.004926","UN",,"31.5","31.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FIDAXOMICIN 200 MG PO TABS","81000000","CDM","0250","RC","52015-080-01","NDC",,,"facility","inpatient","1.090909","UN",,"882.87","882.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THEOPHYLLINE ER 100 MG PO CP24","81000000","CDM","0250","RC","52244-100-10","NDC",,,"facility","inpatient","1.000000","UN",,"18.33","18.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR","81000000","CDM","0250","RC","52268-100-01","NDC",,,"facility","inpatient","5377.859519","ML",,"68.55","68.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 4 % EX SOLN","81000000","CDM","0250","RC","52565-009-50","NDC",,,"facility","inpatient","1","EA",,"323.25","323.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 50.000000 APPLICATION"
"ENALAPRIL 1MG/ML ORAL LIQD (PEDIATRIC) SH","81000000","CDM","0250","RC","52652-4001-1","NDC",,,"facility","inpatient","1.000000","ML",,"25.98","25.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMLODIPINE BENZOATE 1 MG/ML PO SUSP","81000000","CDM","0250","RC","52652-5001-1","NDC",,,"facility","inpatient","155.581540","ML",,"155.50","155.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 5 MG PO TABS","81000000","CDM","0250","RC","52817-319-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMINOCAPROIC ACID 0.25 GM/ML PO SOLN","81000000","CDM","0250","RC","52817-815-08","NDC",,,"facility","inpatient","236.559139","ML",,"192.66","192.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOCARNITINE 1 GM/10ML PO SOLN","81000000","CDM","0250","RC","52817-830-04","NDC",,,"facility","inpatient","117.998208","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICROFIBRILLAR COLL HEMOSTAT EX POWD","81000000","CDM","0250","RC","53276-1010-2","NDC",,,"facility","inpatient","1.000000","GR",,"1160","1160",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICROFIBRILLAR COLL HEMOSTAT EX PADS","81000000","CDM","0250","RC","53276-1010-9","NDC",,,"facility","inpatient","3.400000","EA",,"1160","1160",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROGEN PEROXIDE 3 % EX SOLN","81000000","CDM","0250","RC","53329-981-06","NDC",,,"facility","inpatient","473.933649","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETYLPYRIDINIUM CHLORIDE 0.05 % MT LIQD","81000000","CDM","0250","RC","53462-375-60","NDC",,,"facility","inpatient","7.120689","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE HYCLATE 100 MG PO CAPS","81000000","CDM","0250","RC","53489-119-02","NDC",,,"facility","inpatient","1.133333","UN",,"32.56","32.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 100 MG PO CAPS","81000000","CDM","0250","RC","53746-101-05","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS","81000000","CDM","0250","RC","53746-271-01","NDC",,,"facility","inpatient","1.000000","UN",,"12.27","12.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BETHANECHOL CHLORIDE 5 MG PO TABS","81000000","CDM","0250","RC","53746-571-01","NDC",,,"facility","inpatient","1.125000","UN",,"10.31","10.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESALAMINE 1.2 G PO TBEC","81000000","CDM","0250","RC","54092-476-12","NDC",,,"facility","inpatient","1.000000","UN",,"33.7","33.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRUCALOPRIDE SUCCINATE 1 MG PO TABS","81000000","CDM","0250","RC","54092-546-01","NDC",,,"facility","inpatient","1.000000","UN",,"84.91","84.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINERAL OIL PO OIL","81000000","CDM","0250","RC","54162-190-30","NDC",,,"facility","inpatient","35.760160","ML",,"14.79","14.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ABLYSINOL IA SOLN","81000000","CDM","0250","RC","54288-105-15","NDC",,,"facility","inpatient","6.428571","ML",,"2043.16","2043.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE HCL (NASAL) 0.1 % NA SOLN","81000000","CDM","0250","RC","54288-154-01","NDC",,,"facility","inpatient","30.000000","ML",,"1056","1056",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOCARNITINE 330 MG PO TABS","81000000","CDM","0250","RC","54482-144-07","NDC",,,"facility","inpatient","1.506329","UN",,"0.67","0.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOCARNITINE 1 GM/10ML PO SOLN","81000000","CDM","0250","RC","54482-145-08","NDC",,,"facility","inpatient","118.001750","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFUVITE ADULT IV INJ","81000000","CDM","0250","RC","54643-5649-1","NDC",,,"facility","inpatient","15.232558","ML",,"57.51","57.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCROSE 24% SUCKING SOLN SH","81000000","CDM","0250","RC","54758-00612","NDC",,,"facility","inpatient","1.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCOSE 40% PO GEL (NEONATAL) SH","81000000","CDM","0250","RC","54758-00628","NDC",,,"facility","inpatient","3.491299","ML",,"1.98","1.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUORESCEIN-PROPARACAINE 0.25-0.5 % OP SOLN","81000000","CDM","0250","RC","54799-507-21","NDC",,,"facility","inpatient","5.000000","ML",,"221","221",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN E (TOCOPHEROL ACETATE) 15 UNITS/0.3ML ORAL SYRINGE (NEONATAL) SH","81000000","CDM","0250","RC","54838-005-30","NDC",,,"facility","inpatient","30.093034","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYBUTYNIN CHLORIDE 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","54838-510-80","NDC",,,"facility","inpatient","473.036896","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORATADINE 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","54838-558-40","NDC",,,"facility","inpatient","120.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMIVUDINE 10 MG/ML PO SOLN","81000000","CDM","0250","RC","54838-566-70","NDC",,,"facility","inpatient","239.978183","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMVASTATIN 5 MG PO TABS","81000000","CDM","0250","RC","55111-197-30","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 5 MG PO TBDP","81000000","CDM","0250","RC","55111-262-79","NDC",,,"facility","inpatient","1.382089","UN",,"15.15","15.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 10 MG PO TBDP","81000000","CDM","0250","RC","55111-263-79","NDC",,,"facility","inpatient","1.000000","UN",,"16.78","16.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOPIDOGREL BISULFATE 300 MG PO TABS","81000000","CDM","0250","RC","55111-671-31","NDC",,,"facility","inpatient","1.000000","UN",,"83.53","83.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAFCILLIN 2 GM/100ML NS (MINIBAG)","81000000","CDM","0250","RC","55150-123-15","NDC",,,"facility","inpatient","1.022988","UN",,"105","105",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOMIDATE 2 MG/ML IV SOLN","81000000","CDM","0250","RC","55150-221-10","NDC",,,"facility","inpatient","11.785714","ML",,"71.59","71.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VECURONIUM 1MG/ML SW INJ (PEDIATRIC) SH","81000000","CDM","0250","RC","55150-235-02","NDC",,,"facility","inpatient","1.000000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VECURONIUM BROMIDE 10 MG IV SOLR","81000000","CDM","0250","RC","55150-235-10","NDC",,,"facility","inpatient","1.151969","UN",,"70.44","70.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VECURONIUM BROMIDE 20 MG IV SOLR","81000000","CDM","0250","RC","55150-236-20","NDC",,,"facility","inpatient","1.000000","UN",,"94.5","94.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL 10 MG/ML IJ SOLN","81000000","CDM","0250","RC","55150-438-10","NDC",,,"facility","inpatient","5.072770","ML",,"116.67","116.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL 50 MG/ML IJ SOLN","81000000","CDM","0250","RC","55150-439-01","NDC",,,"facility","inpatient","13.636363","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE 100 MG/100ML NS (MINIBAG)","81000000","CDM","0250","RC","55390-110-10","NDC",,,"facility","inpatient","100.000000","ML",,"101.5","101.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEKAS PLUS PO LIQD","81000000","CDM","0250","RC","55520-00163","NDC",,,"facility","inpatient","59.994990","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DINOPROSTONE 10 MG VA INST","81000000","CDM","0250","RC","55566-2800-1","NDC",,,"facility","inpatient","1.156250","UN",,"1559.00","1559.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIRTAZAPINE 15 MG PO TBDP","81000000","CDM","0250","RC","57237-011-06","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIRTAZAPINE 30 MG PO TBDP","81000000","CDM","0250","RC","57237-012-06","NDC",,,"facility","inpatient","1.000000","UN",,"10.19","10.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 30 MG PO CPEP","81000000","CDM","0250","RC","57237-018-30","NDC",,,"facility","inpatient","1.149068","UN",,"41.02","41.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 60 MG PO CPEP","81000000","CDM","0250","RC","57237-019-30","NDC",,,"facility","inpatient","1.166666","UN",,"42.01","42.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN V POTASSIUM 250 MG PO TABS","81000000","CDM","0250","RC","57237-040-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN V POTASSIUM 500 MG PO TABS","81000000","CDM","0250","RC","57237-041-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 4 MG PO TBDP","81000000","CDM","0250","RC","57237-077-10","NDC",,,"facility","inpatient","1.154658","UN",,"75.57","75.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 4 MG PO TBDP","81000000","CDM","0250","RC","57237-077-10","NDC",,,"facility","inpatient","1.000000","UN","PN","89.13","89.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ALFUZOSIN HCL ER 10 MG PO TB24","81000000","CDM","0250","RC","57237-114-90","NDC",,,"facility","inpatient","1.000000","UN",,"23.18","23.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 40 MG/ML PO SUSR","81000000","CDM","0250","RC","57237-150-35","NDC",,,"facility","inpatient","34.999930","ML",,"77.13","77.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMIVUDINE 10 MG/ML PO SOLN","81000000","CDM","0250","RC","57237-274-24","NDC",,,"facility","inpatient","239.923224","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","57664-126-88","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL TARTRATE 50 MG PO TABS","81000000","CDM","0250","RC","57664-166-52","NDC",,,"facility","inpatient","1.555555","UN",,"9.55","9.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINOCYCLINE HCL 100 MG PO CAPS","81000000","CDM","0250","RC","57664-853-85","NDC",,,"facility","inpatient","1.000000","UN",,"18.68","18.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXEGOL OXALATE 12.5 MG PO TABS","81000000","CDM","0250","RC","57841-1300-1","NDC",,,"facility","inpatient","1.000000","UN",,"63.33","63.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXEGOL OXALATE 25 MG PO TABS","81000000","CDM","0250","RC","57841-1301-1","NDC",,,"facility","inpatient","1.000000","UN",,"63.33","63.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN ZINC 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","57896-145-14","NDC",,,"facility","inpatient","1.111111","UN",,"2.29","2.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % OP SOLN","81000000","CDM","0250","RC","57896-181-05","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 250 MG PO CAPS","81000000","CDM","0250","RC","57896-426-01","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OYSTER SHELL CALCIUM/VITAMIN D 250-3.125 MG-MCG PO TABS","81000000","CDM","0250","RC","57896-731-01","NDC",,,"facility","inpatient","1.000000","UN",,"1.47","1.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN","81000000","CDM","0250","RC","58177-886-05","NDC",,,"facility","inpatient","255.848139","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 800 MG PO TABS","81000000","CDM","0250","RC","58468-0130-1","NDC",,,"facility","inpatient","1.119402","UN",,"32.90","32.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 0.8 G PO PACK","81000000","CDM","0250","RC","58468-0132-2","NDC",,,"facility","inpatient","1.857142","UN",,"77.65","77.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLOPATADINE HCL 0.1 % OP SOLN","81000000","CDM","0250","RC","58602-006-40","NDC",,,"facility","inpatient","5.000000","ML",,"59.28","59.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORATADINE 10 MG PO TABS","81000000","CDM","0250","RC","58602-702-04","NDC",,,"facility","inpatient","1.111744","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 250 MG PO TABS","81000000","CDM","0250","RC","58657-675-01","NDC",,,"facility","inpatient","1.016806","UN",,"24.31","24.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 10440-39150 UNITS PO TABS","81000000","CDM","0250","RC","58914-112-10","NDC",,,"facility","inpatient","1.000000","UN",,"21.24","21.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 % PR OINT","81000000","CDM","0250","RC","58914-301-80","NDC",,,"facility","inpatient","30.000000","GR",,"2306.7","2306.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESALAMINE 1000 MG PR SUPP","81000000","CDM","0250","RC","58914-501-56","NDC",,,"facility","inpatient","1.000000","UN",,"139.41","139.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN ZINC 500 UNIT/GM EX OINT","81000000","CDM","0250","RC","58980-011-10","NDC",,,"facility","inpatient","28.350000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL ER 10 MG PO T12A","81000000","CDM","0250","RC","59011-410-20","NDC",,,"facility","inpatient","1.101734","UN",,"36.11","36.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL ER 20 MG PO T12A","81000000","CDM","0250","RC","59011-420-10","NDC",,,"facility","inpatient","1.028985","UN",,"58.82","58.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL ER 20 MG PO T12A","81000000","CDM","0250","RC","59011-420-20","NDC",,,"facility","inpatient","1.055363","UN",,"61.44","61.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL ER 40 MG PO T12A","81000000","CDM","0250","RC","59011-440-10","NDC",,,"facility","inpatient","1.094674","UN",,"77.86","77.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL ER 40 MG PO T12A","81000000","CDM","0250","RC","59011-440-20","NDC",,,"facility","inpatient","1.000000","UN",,"79.19","79.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL ER 80 MG PO T12A","81000000","CDM","0250","RC","59011-480-20","NDC",,,"facility","inpatient","1.000000","UN",,"109.73","109.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMINOLEVULINIC ACID HCL 1.5 G PO SOLR","81000000","CDM","0250","RC","59137-231-01","NDC",,,"facility","inpatient","1.000000","UN",,"5780.94","5780.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 2 MG PO TABS","81000000","CDM","0250","RC","59148-006-13","NDC",,,"facility","inpatient","1.000000","UN",,"93.41","93.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 5 MG PO TABS","81000000","CDM","0250","RC","59148-007-13","NDC",,,"facility","inpatient","2.333333","UN",,"75.25","75.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 20 MG PO TABS","81000000","CDM","0250","RC","59148-010-13","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","81000000","CDM","0250","RC","59310-579-22","NDC",,,"facility","inpatient","8.500000","GM",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERRIC SUBSULFATE 259 MG/GM EX SOLN","81000000","CDM","0250","RC","59365-6065-1","NDC",,,"facility","inpatient","8.000000","GM",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM ACETATE (PHOS BINDER) 667 MG PO TABS","81000000","CDM","0250","RC","59528-0331-2","NDC",,,"facility","inpatient","1.043010","UN",,"9","9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOFETILIDE 500 MCG PO CAPS","81000000","CDM","0250","RC","59651-120-60","NDC",,,"facility","inpatient","1.727272","UN",,"47.1","47.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPAFENONE HCL 150 MG PO TABS","81000000","CDM","0250","RC","59651-256-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.73","7.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA 25-100 MG PO TABS","81000000","CDM","0250","RC","59651-457-01","NDC",,,"facility","inpatient","1.093196","UN",,"10.41","10.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RILPIVIRINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","59676-278-01","NDC",,,"facility","inpatient","1.000000","UN",,"170.98","170.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DARUNAVIR 600 MG PO TABS","81000000","CDM","0250","RC","59676-562-01","NDC",,,"facility","inpatient","1.000000","UN",,"127.04","127.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DARUNAVIR 800 MG PO TABS","81000000","CDM","0250","RC","59676-566-30","NDC",,,"facility","inpatient","1.000000","UN",,"258.98","258.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETRAVIRINE 100 MG PO TABS","81000000","CDM","0250","RC","59676-570-01","NDC",,,"facility","inpatient","1.000000","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DARUNAVIR-COBICISTAT 800-150 MG PO TABS","81000000","CDM","0250","RC","59676-575-30","NDC",,,"facility","inpatient","1.200000","UN",,"296.01","296.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG PO TABS","81000000","CDM","0250","RC","59676-800-30","NDC",,,"facility","inpatient","1.000000","UN",,"562.78","562.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 0.5 MG PO TBDP","81000000","CDM","0250","RC","59746-010-32","NDC",,,"facility","inpatient","1.000000","UN",,"27.04","27.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 2 MG PO TBDP","81000000","CDM","0250","RC","59746-030-22","NDC",,,"facility","inpatient","1.235294","UN",,"47.14","47.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERAZOSIN HCL 1 MG PO CAPS","81000000","CDM","0250","RC","59746-383-06","NDC",,,"facility","inpatient","1.337349","UN",,"13.48","13.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 5 MG PO TABS","81000000","CDM","0250","RC","59762-0073-1","NDC",,,"facility","inpatient","1.023088","UN",,"10.45","10.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 20 MG PO TABS","81000000","CDM","0250","RC","59762-0075-1","NDC",,,"facility","inpatient","1.063481","UN",,"14.57","14.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LATANOPROST 0.005 % OP SOLN","81000000","CDM","0250","RC","59762-0333-2","NDC",,,"facility","inpatient","2.988281","ML",,"377.26","377.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 40 MG/ML PO SUSR","81000000","CDM","0250","RC","59762-0935-3","NDC",,,"facility","inpatient","75.000468","ML",,"347.66","347.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIOTHYRONINE SODIUM 5 MCG PO TABS","81000000","CDM","0250","RC","59762-1206-1","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESVENLAFAXINE SUCCINATE ER 25 MG PO TB24","81000000","CDM","0250","RC","59762-1210-3","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPLERENONE 25 MG PO TABS","81000000","CDM","0250","RC","59762-1710-2","NDC",,,"facility","inpatient","1.307692","UN",,"20.97","20.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 250 MG PO TABS","81000000","CDM","0250","RC","59762-3060-3","NDC",,,"facility","inpatient","1.000000","UN",,"28.42","28.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 200 MG/5ML PO SUSR","81000000","CDM","0250","RC","59762-3140-1","NDC",,,"facility","inpatient","29.999531","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG SL SUBL","81000000","CDM","0250","RC","59762-3304-3","NDC",,,"facility","inpatient","25.000000","UN",,"128.38","128.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 0.5 MG PO TABS","81000000","CDM","0250","RC","59762-3720-1","NDC",,,"facility","inpatient","1.112676","UN",,"23.40","23.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFASALAZINE 500 MG PO TABS","81000000","CDM","0250","RC","59762-5000-5","NDC",,,"facility","inpatient","1.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETRAVIRINE 100 MG PO TABS","81000000","CDM","0250","RC","60219-1721-7","NDC",,,"facility","inpatient","1.000000","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATROPINE SULFATE 1 % OP SOLN","81000000","CDM","0250","RC","60219-1748-2","NDC",,,"facility","inpatient","2.000000","ML",,"239.3","239.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATROPINE 1% DROPS SOLN (FOR SUBLINGUAL USE)","81000000","CDM","0250","RC","60219-1749-3","NDC",,,"facility","inpatient","7.448979","ML",,"291.9","291.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENOFIBRATE 160 MG PO TABS","81000000","CDM","0250","RC","60219-5522-9","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG PO PACK","81000000","CDM","0250","RC","60258-006-01","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG PO PACK","81000000","CDM","0250","RC","60258-006-15","NDC",,,"facility","inpatient","1.019370","UN",,"1.71","1.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEPHRO-VITE RX 1 MG PO TABS","81000000","CDM","0250","RC","60258-161-01","NDC",,,"facility","inpatient","1.032462","UN",,"2.01","2.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM OXIDE -MG SUPPLEMENT 400 (240 MG) MG PO TABS","81000000","CDM","0250","RC","60258-171-01","NDC",,,"facility","inpatient","1.000000","UN",,"1.08","1.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENTOXIFYLLINE ER 400 MG PO TBCR","81000000","CDM","0250","RC","60505-0033-6","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OMEPRAZOLE 20 MG PO CPDR","81000000","CDM","0250","RC","60505-0065-2","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUVOXAMINE MALEATE 50 MG PO TABS","81000000","CDM","0250","RC","60505-0165-1","NDC",,,"facility","inpatient","1.000000","UN",,"14.16","14.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE 0.1 MG PO TABS","81000000","CDM","0250","RC","60505-0257-1","NDC",,,"facility","inpatient","1.000000","UN",,"15.21","15.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OFLOXACIN 0.3 % OT SOLN","81000000","CDM","0250","RC","60505-0363-1","NDC",,,"facility","inpatient","1","EA",,"617.12","617.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 94.047619 DROP"
"OFLOXACIN 0.3 % OP SOLN","81000000","CDM","0250","RC","60505-0560-0","NDC",,,"facility","inpatient","5.000000","ML",,"104.7","104.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE SPRAY 0.01 % NA SOLN","81000000","CDM","0250","RC","60505-0815-0","NDC",,,"facility","inpatient","0.124378","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP","81000000","CDM","0250","RC","60505-0829-1","NDC",,,"facility","inpatient","16.000000","GR",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC TROMETHAMINE 0.5 % OP SOLN","81000000","CDM","0250","RC","60505-1003-1","NDC",,,"facility","inpatient","5.000000","ML",,"427.48","427.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 40 MG PO TABS","81000000","CDM","0250","RC","60505-2580-9","NDC",,,"facility","inpatient","1.247030","UN",,"29.97","29.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 2.5 MG PO TABS","81000000","CDM","0250","RC","60505-3110-0","NDC",,,"facility","inpatient","1.055363","UN",,"50.68","50.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 5 MG PO TABS","81000000","CDM","0250","RC","60505-3111-0","NDC",,,"facility","inpatient","1.164383","UN",,"50.42","50.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 10 MG PO TABS","81000000","CDM","0250","RC","60505-3113-0","NDC",,,"facility","inpatient","1.000000","UN",,"70.19","70.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMIVUDINE 100 MG PO TABS","81000000","CDM","0250","RC","60505-3250-6","NDC",,,"facility","inpatient","1.000000","UN",,"51.95","51.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 5 MG PO TBDP","81000000","CDM","0250","RC","60505-3275-0","NDC",,,"facility","inpatient","1.617604","UN",,"46.77","46.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 5 MG PO TBDP","81000000","CDM","0250","RC","60505-3275-3","NDC",,,"facility","inpatient","1.114285","UN",,"51.54","51.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUANFACINE HCL ER 1 MG PO TB24","81000000","CDM","0250","RC","60505-3927-1","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUANFACINE HCL ER 2 MG PO TB24","81000000","CDM","0250","RC","60505-3928-1","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 12 MCG/HR TD PT72","81000000","CDM","0250","RC","60505-7080-2","NDC",,,"facility","inpatient","1.000000","UN",,"81.2","81.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 25 MCG/HR TD PT72","81000000","CDM","0250","RC","60505-7081-2","NDC",,,"facility","inpatient","1.210526","UN",,"85.08","85.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 50 MCG/HR TD PT72","81000000","CDM","0250","RC","60505-7082-2","NDC",,,"facility","inpatient","1.571428","UN",,"116.64","116.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 100 MCG/HR TD PT72","81000000","CDM","0250","RC","60505-7084-2","NDC",,,"facility","inpatient","2.333333","UN",,"236.13","236.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"URSODIOL 300 MG PO CAPS","81000000","CDM","0250","RC","60687-100-01","NDC",,,"facility","inpatient","1.050012","UN",,"38.82","38.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEDROXYPROGESTERONE ACETATE 10 MG PO TABS","81000000","CDM","0250","RC","60687-105-21","NDC",,,"facility","inpatient","1.000000","UN",,"9.22","9.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE HCL 0.1 MG PO TABS","81000000","CDM","0250","RC","60687-113-11","NDC",,,"facility","inpatient","1.061702","UN",,"9.55","9.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE HCL 0.2 MG PO TABS","81000000","CDM","0250","RC","60687-124-11","NDC",,,"facility","inpatient","1.041666","UN",,"12.43","12.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 100 MG PO CAPS","81000000","CDM","0250","RC","60687-129-01","NDC",,,"facility","inpatient","1.013289","UN",,"1.61","1.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METFORMIN HCL 850 MG PO TABS","81000000","CDM","0250","RC","60687-143-01","NDC",,,"facility","inpatient","1.181818","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 250 MG PO CAPS","81000000","CDM","0250","RC","60687-152-01","NDC",,,"facility","inpatient","1.012403","UN",,"7.39","7.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METFORMIN HCL 500 MG PO TABS","81000000","CDM","0250","RC","60687-155-01","NDC",,,"facility","inpatient","1.000000","UN",,"9.17","9.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYTOIN 50 MG PO CHEW","81000000","CDM","0250","RC","60687-156-25","NDC",,,"facility","inpatient","1.000000","UN",,"10.3","10.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 500 MG PO CAPS","81000000","CDM","0250","RC","60687-163-01","NDC",,,"facility","inpatient","1.107033","UN",,"14.94","14.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAVASTATIN SODIUM 20 MG PO TABS","81000000","CDM","0250","RC","60687-178-01","NDC",,,"facility","inpatient","1.000000","UN",,"17.88","17.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 10 MG PO TABS","81000000","CDM","0250","RC","60687-179-01","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEMANTINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","60687-184-57","NDC",,,"facility","inpatient","1.045977","UN",,"14.68","14.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENTACAPONE 200 MG PO TABS","81000000","CDM","0250","RC","60687-188-21","NDC",,,"facility","inpatient","1.000000","UN",,"27.17","27.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24","81000000","CDM","0250","RC","60687-195-01","NDC",,,"facility","inpatient","1.300341","UN",,"13.29","13.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24","81000000","CDM","0250","RC","60687-206-01","NDC",,,"facility","inpatient","1.162162","UN",,"13.71","13.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM 125 MG PO TBEC","81000000","CDM","0250","RC","60687-211-21","NDC",,,"facility","inpatient","1.000000","UN",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENTECAVIR 0.5 MG PO TABS","81000000","CDM","0250","RC","60687-216-25","NDC",,,"facility","inpatient","1.064935","UN",,"88.60","88.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24","81000000","CDM","0250","RC","60687-217-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMFIBROZIL 600 MG PO TABS","81000000","CDM","0250","RC","60687-224-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24","81000000","CDM","0250","RC","60687-228-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOPERAMIDE HCL 2 MG PO CAPS","81000000","CDM","0250","RC","60687-229-01","NDC",,,"facility","inpatient","1.048034","UN",,"1.49","1.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZONISAMIDE 100 MG PO CAPS","81000000","CDM","0250","RC","60687-230-01","NDC",,,"facility","inpatient","2.000000","UN",,"9.94","9.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","60687-231-01","NDC",,,"facility","inpatient","1.204603","UN",,"9.18","9.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROSUVASTATIN CALCIUM 5 MG PO TABS","81000000","CDM","0250","RC","60687-234-01","NDC",,,"facility","inpatient","1.914285","UN",,"27.89","27.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","60687-242-01","NDC",,,"facility","inpatient","1.057420","UN",,"9.87","9.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOXETINE HCL 20 MG/5ML PO SOLN","81000000","CDM","0250","RC","60687-244-40","NDC",,,"facility","inpatient","5.049382","ML",,"39.12","39.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SERTRALINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","60687-253-01","NDC",,,"facility","inpatient","1.238698","UN",,"11.61","11.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROSUVASTATIN CALCIUM 20 MG PO TABS","81000000","CDM","0250","RC","60687-256-01","NDC",,,"facility","inpatient","1.000000","UN",,"30.93","30.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","81000000","CDM","0250","RC","60687-267-42","NDC",,,"facility","inpatient","50.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFUROXIME AXETIL 250 MG PO TABS","81000000","CDM","0250","RC","60687-272-94","NDC",,,"facility","inpatient","1.000000","UN",,"22.69","22.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORTRIPTYLINE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","60687-281-01","NDC",,,"facility","inpatient","1.358208","UN",,"10.36","10.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DONEPEZIL HCL 5 MG PO TABS","81000000","CDM","0250","RC","60687-292-01","NDC",,,"facility","inpatient","1.300000","UN",,"13.48","13.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORTRIPTYLINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","60687-293-01","NDC",,,"facility","inpatient","1.000000","UN",,"12.17","12.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ITRACONAZOLE 100 MG PO CAPS","81000000","CDM","0250","RC","60687-299-25","NDC",,,"facility","inpatient","1.000000","UN",,"22","22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NADOLOL 20 MG PO TABS","81000000","CDM","0250","RC","60687-302-25","NDC",,,"facility","inpatient","1.039682","UN",,"18.56","18.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DONEPEZIL HCL 10 MG PO TABS","81000000","CDM","0250","RC","60687-303-01","NDC",,,"facility","inpatient","1.028268","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CAPTOPRIL 12.5 MG PO TABS","81000000","CDM","0250","RC","60687-304-21","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 150 MG PO TB24","81000000","CDM","0250","RC","60687-312-01","NDC",,,"facility","inpatient","1.000000","UN",,"25.62","25.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUETIAPINE FUMARATE 25 MG PO TABS","81000000","CDM","0250","RC","60687-327-01","NDC",,,"facility","inpatient","1.082329","UN",,"19.27","19.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 800 MG PO TABS","81000000","CDM","0250","RC","60687-328-11","NDC",,,"facility","inpatient","1.000000","UN",,"38.16","38.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 800 MG PO TABS","81000000","CDM","0250","RC","60687-328-31","NDC",,,"facility","inpatient","1.000000","UN",,"35.97","35.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 20 MG PO TABS","81000000","CDM","0250","RC","60687-333-01","NDC",,,"facility","inpatient","1.313725","UN",,"9.41","9.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINOCYCLINE HCL 100 MG PO CAPS","81000000","CDM","0250","RC","60687-336-65","NDC",,,"facility","inpatient","1.000000","UN",,"10.66","10.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL 75 MG PO TABS","81000000","CDM","0250","RC","60687-340-01","NDC",,,"facility","inpatient","1.076923","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL 100 MG PO TABS","81000000","CDM","0250","RC","60687-351-01","NDC",,,"facility","inpatient","1.039215","UN",,"14.93","14.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","60687-369-01","NDC",,,"facility","inpatient","1.040816","UN",,"10.29","10.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EZETIMIBE 10 MG PO TABS","81000000","CDM","0250","RC","60687-373-21","NDC",,,"facility","inpatient","1.126903","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHYTONADIONE 5 MG PO TABS","81000000","CDM","0250","RC","60687-381-94","NDC",,,"facility","inpatient","1.017857","UN",,"1.29","1.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 2.5 MG PO TABS","81000000","CDM","0250","RC","60687-387-11","NDC",,,"facility","inpatient","1.121212","UN",,"10.30","10.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPRAZOLAM 0.5 MG PO TABS","81000000","CDM","0250","RC","60687-388-11","NDC",,,"facility","inpatient","1.000000","UN",,"23.09","23.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLCHICINE 0.6 MG PO TABS","81000000","CDM","0250","RC","60687-389-21","NDC",,,"facility","inpatient","1.000000","UN",,"53.11","53.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL SUCCINATE ER 25 MG PO TB24","81000000","CDM","0250","RC","60687-390-01","NDC",,,"facility","inpatient","1.096618","UN",,"13.01","13.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESALAMINE 1.2 G PO TBEC","81000000","CDM","0250","RC","60687-397-25","NDC",,,"facility","inpatient","1.095808","UN",,"43.77","43.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","60687-398-11","NDC",,,"facility","inpatient","1.017825","UN",,"7.94","7.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESALAMINE 800 MG PO TBEC","81000000","CDM","0250","RC","60687-408-25","NDC",,,"facility","inpatient","1.000000","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","60687-409-25","NDC",,,"facility","inpatient","1.033862","UN",,"14.07","14.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS","81000000","CDM","0250","RC","60687-418-01","NDC",,,"facility","inpatient","1.079365","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RITONAVIR 100 MG PO TABS","81000000","CDM","0250","RC","60687-420-25","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBAZAM 10 MG PO TABS","81000000","CDM","0250","RC","60687-423-21","NDC",,,"facility","inpatient","1.046783","UN",,"27.86","27.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","81000000","CDM","0250","RC","60687-429-45","NDC",,,"facility","inpatient","30.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYETHYLENE GLYCOL 3350 17 G PO PACK","81000000","CDM","0250","RC","60687-431-99","NDC",,,"facility","inpatient","1.179793","UN",,"1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAZODONE HCL 150 MG PO TABS","81000000","CDM","0250","RC","60687-432-11","NDC",,,"facility","inpatient","1.270270","UN",,"9.00","9.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","60687-433-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 100 MG PO TABS","81000000","CDM","0250","RC","60687-439-11","NDC",,,"facility","inpatient","1.137000","UN",,"8.44","8.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAZODONE HCL 50 MG PO TABS","81000000","CDM","0250","RC","60687-443-01","NDC",,,"facility","inpatient","1.010315","UN",,"11.24","11.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","60687-444-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 200 MG PO TABS","81000000","CDM","0250","RC","60687-450-11","NDC",,,"facility","inpatient","1.030100","UN",,"9.57","9.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPLERENONE 25 MG PO TABS","81000000","CDM","0250","RC","60687-451-11","NDC",,,"facility","inpatient","1.081632","UN",,"27.36","27.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 25 MCG PO TABS","81000000","CDM","0250","RC","60687-453-11","NDC",,,"facility","inpatient","1.061084","UN",,"7.45","7.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 300 MG PO TABS","81000000","CDM","0250","RC","60687-461-11","NDC",,,"facility","inpatient","1.013289","UN",,"11.32","11.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 50 MCG PO TABS","81000000","CDM","0250","RC","60687-464-11","NDC",,,"facility","inpatient","1.028975","UN",,"12.25","12.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROFURANTOIN MACROCRYSTAL 50 MG PO CAPS","81000000","CDM","0250","RC","60687-472-11","NDC",,,"facility","inpatient","1.000000","UN",,"24.3","24.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 25 MG PO CAPS","81000000","CDM","0250","RC","60687-473-11","NDC",,,"facility","inpatient","1.124087","UN",,"22.58","22.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 75 MCG PO TABS","81000000","CDM","0250","RC","60687-475-11","NDC",,,"facility","inpatient","1.057528","UN",,"12.40","12.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 50 MG PO TABS","81000000","CDM","0250","RC","60687-476-11","NDC",,,"facility","inpatient","1.038277","UN",,"10.2","10.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL 2 MG SL SUBL","81000000","CDM","0250","RC","60687-481-11","NDC",,,"facility","inpatient","1.106666","UN",,"20.56","20.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 50 MG PO CAPS","81000000","CDM","0250","RC","60687-484-11","NDC",,,"facility","inpatient","1.000000","UN",,"33.34","33.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 88 MCG PO TABS","81000000","CDM","0250","RC","60687-486-11","NDC",,,"facility","inpatient","1.130081","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 100 MG PO TABS","81000000","CDM","0250","RC","60687-487-11","NDC",,,"facility","inpatient","1.064576","UN",,"12.21","12.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPRENORPHINE HCL 8 MG SL SUBL","81000000","CDM","0250","RC","60687-492-11","NDC",,,"facility","inpatient","1.091554","UN",,"36.47","36.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL ER 120 MG PO TBCR","81000000","CDM","0250","RC","60687-493-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 75 MG PO CAPS","81000000","CDM","0250","RC","60687-495-11","NDC",,,"facility","inpatient","1.415122","UN",,"21.96","21.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG PO TABS","81000000","CDM","0250","RC","60687-497-11","NDC",,,"facility","inpatient","1.129801","UN",,"13.33","13.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 10 MG PO TABS","81000000","CDM","0250","RC","60687-503-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREGABALIN 100 MG PO CAPS","81000000","CDM","0250","RC","60687-506-11","NDC",,,"facility","inpatient","1.268656","UN",,"27.61","27.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 112 MCG PO TABS","81000000","CDM","0250","RC","60687-508-11","NDC",,,"facility","inpatient","1.135398","UN",,"14.85","14.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE HYCLATE 100 MG PO CAPS","81000000","CDM","0250","RC","60687-513-11","NDC",,,"facility","inpatient","1.063492","UN",,"14.98","14.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 800 MG PO TABS","81000000","CDM","0250","RC","60687-518-11","NDC",,,"facility","inpatient","1.250000","UN",,"15.80","15.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 125 MCG PO TABS","81000000","CDM","0250","RC","60687-519-11","NDC",,,"facility","inpatient","1.028483","UN",,"13.99","13.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POSACONAZOLE 100 MG PO TBEC","81000000","CDM","0250","RC","60687-523-11","NDC",,,"facility","inpatient","1.000000","UN",,"169.8","169.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 150 MCG PO TABS","81000000","CDM","0250","RC","60687-530-11","NDC",,,"facility","inpatient","1.117936","UN",,"13.75","13.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATOVAQUONE 750 MG/5ML PO SUSP","81000000","CDM","0250","RC","60687-534-36","NDC",,,"facility","inpatient","5.303030","ML",,"171.45","171.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATOVAQUONE 750 MG/5ML PO SUSP","81000000","CDM","0250","RC","60687-534-40","NDC",,,"facility","inpatient","5.000000","ML",,"177.85","177.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 2 MG PO TABS","81000000","CDM","0250","RC","60687-535-11","NDC",,,"facility","inpatient","1.025236","UN",,"10.79","10.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FEBUXOSTAT 40 MG PO TABS","81000000","CDM","0250","RC","60687-538-11","NDC",,,"facility","inpatient","1.064000","UN",,"16.5","16.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 0.5 MG PO TABS","81000000","CDM","0250","RC","60687-544-11","NDC",,,"facility","inpatient","1.225294","UN",,"30.94","30.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RANOLAZINE ER 500 MG PO TB12","81000000","CDM","0250","RC","60687-549-11","NDC",,,"facility","inpatient","1.095238","UN",,"12.25","12.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG PO TABS","81000000","CDM","0250","RC","60687-550-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 200 MCG PO TABS","81000000","CDM","0250","RC","60687-552-01","NDC",,,"facility","inpatient","1.048780","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 1 MG PO TABS","81000000","CDM","0250","RC","60687-555-11","NDC",,,"facility","inpatient","1.000000","UN",,"16.60","16.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESALAMINE 400 MG PO CPDR","81000000","CDM","0250","RC","60687-556-33","NDC",,,"facility","inpatient","1.073126","UN",,"27.45","27.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOBENZAPRINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","60687-558-11","NDC",,,"facility","inpatient","1.023193","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHOCARBAMOL 500 MG PO TABS","81000000","CDM","0250","RC","60687-559-11","NDC",,,"facility","inpatient","1.000000","UN",,"8.29","8.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS","81000000","CDM","0250","RC","60687-570-11","NDC",,,"facility","inpatient","7.400000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIFAMPIN 150 MG PO CAPS","81000000","CDM","0250","RC","60687-575-11","NDC",,,"facility","inpatient","1.000000","UN",,"21.01","21.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 2 MG/ML PO SYRP","81000000","CDM","0250","RC","60687-576-40","NDC",,,"facility","inpatient","5.320834","ML",,"38.98","38.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE ER 500 MG PO CP12","81000000","CDM","0250","RC","60687-578-11","NDC",,,"facility","inpatient","1.000000","UN",,"31.38","31.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG PO TABS","81000000","CDM","0250","RC","60687-579-11","NDC",,,"facility","inpatient","1.131021","UN",,"23.58","23.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 100 MG PO CAPS","81000000","CDM","0250","RC","60687-580-11","NDC",,,"facility","inpatient","1.046242","UN",,"11.84","11.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.5 MG PO TABS","81000000","CDM","0250","RC","60687-581-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 10 MG PO TABS","81000000","CDM","0250","RC","60687-582-11","NDC",,,"facility","inpatient","1.000000","UN",,"14.32","14.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","81000000","CDM","0250","RC","60687-585-11","NDC",,,"facility","inpatient","1.015564","UN",,"20.9","20.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIFAMPIN 300 MG PO CAPS","81000000","CDM","0250","RC","60687-586-11","NDC",,,"facility","inpatient","1.019801","UN",,"12.88","12.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 10 MG PO TABS","81000000","CDM","0250","RC","60687-587-11","NDC",,,"facility","inpatient","1.121212","UN",,"12.54","12.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 4 MG PO TABS","81000000","CDM","0250","RC","60687-590-11","NDC",,,"facility","inpatient","1.078175","UN",,"31.25","31.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 300 MG PO CAPS","81000000","CDM","0250","RC","60687-591-11","NDC",,,"facility","inpatient","1.047267","UN",,"10.75","10.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS","81000000","CDM","0250","RC","60687-592-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCHLOROTHIAZIDE 25 MG PO TABS","81000000","CDM","0250","RC","60687-593-11","NDC",,,"facility","inpatient","1.308921","UN",,"14.77","14.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 20 MG PO TABS","81000000","CDM","0250","RC","60687-595-01","NDC",,,"facility","inpatient","1.091954","UN",,"1.95","1.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 3 MG PO CPEP","81000000","CDM","0250","RC","60687-596-33","NDC",,,"facility","inpatient","1.000000","UN",,"64.8","64.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 20 MG PO TABS","81000000","CDM","0250","RC","60687-598-11","NDC",,,"facility","inpatient","1.073770","UN",,"10.85","10.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCYTOSINE 250 MG PO CAPS","81000000","CDM","0250","RC","60687-599-11","NDC",,,"facility","inpatient","1.000000","UN",,"294.71","294.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 400 MG PO CAPS","81000000","CDM","0250","RC","60687-602-11","NDC",,,"facility","inpatient","1.161339","UN",,"8.42","8.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS","81000000","CDM","0250","RC","60687-603-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 40 MG PO TABS","81000000","CDM","0250","RC","60687-609-11","NDC",,,"facility","inpatient","1.101265","UN",,"9.33","9.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALSARTAN 40 MG PO TABS","81000000","CDM","0250","RC","60687-612-11","NDC",,,"facility","inpatient","1.030476","UN",,"11.48","11.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENOFIBRATE 48 MG PO TABS","81000000","CDM","0250","RC","60687-618-11","NDC",,,"facility","inpatient","1.181818","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 5 MG PO TABS","81000000","CDM","0250","RC","60687-620-11","NDC",,,"facility","inpatient","1.026666","UN",,"14.48","14.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALSARTAN 80 MG PO TABS","81000000","CDM","0250","RC","60687-623-11","NDC",,,"facility","inpatient","1.031496","UN",,"13.24","13.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 0.5 MG PO TABS","81000000","CDM","0250","RC","60687-627-11","NDC",,,"facility","inpatient","1.052219","UN",,"35.68","35.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENOFIBRATE 145 MG PO TABS","81000000","CDM","0250","RC","60687-629-21","NDC",,,"facility","inpatient","1.000000","UN",,"15.39","15.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 10 MG PO TABS","81000000","CDM","0250","RC","60687-631-11","NDC",,,"facility","inpatient","1.144578","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS","81000000","CDM","0250","RC","60687-633-11","NDC",,,"facility","inpatient","1.203389","UN",,"19.42","19.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALSARTAN 160 MG PO TABS","81000000","CDM","0250","RC","60687-634-11","NDC",,,"facility","inpatient","1.150943","UN",,"11.09","11.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 1 MG PO TABS","81000000","CDM","0250","RC","60687-638-11","NDC",,,"facility","inpatient","1.125000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","60687-642-11","NDC",,,"facility","inpatient","1.153846","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 2.5 MG PO TABS","81000000","CDM","0250","RC","60687-656-11","NDC",,,"facility","inpatient","1.036951","UN",,"11.93","11.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA 25-100 MG PO TABS","81000000","CDM","0250","RC","60687-661-11","NDC",,,"facility","inpatient","1.037609","UN",,"8.79","8.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","60687-664-11","NDC",,,"facility","inpatient","1.026845","UN",,"14.34","14.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENOFIBRATE 160 MG PO TABS","81000000","CDM","0250","RC","60687-666-11","NDC",,,"facility","inpatient","2.333333","UN",,"39.21","39.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHIMAZOLE 5 MG PO TABS","81000000","CDM","0250","RC","60687-669-11","NDC",,,"facility","inpatient","1.512000","UN",,"13.94","13.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYBUTYNIN CHLORIDE 5 MG PO TABS","81000000","CDM","0250","RC","60687-670-11","NDC",,,"facility","inpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 100 MG PO TABS","81000000","CDM","0250","RC","60687-677-11","NDC",,,"facility","inpatient","1.000000","UN",,"12.19","12.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHIMAZOLE 10 MG PO TABS","81000000","CDM","0250","RC","60687-680-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOLIC ACID 1 MG PO TABS","81000000","CDM","0250","RC","60687-681-11","NDC",,,"facility","inpatient","1.020925","UN",,"1.96","1.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 100 MG PO TABS","81000000","CDM","0250","RC","60687-687-11","NDC",,,"facility","inpatient","1.015384","UN",,"31.68","31.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCRALFATE 1 G PO TABS","81000000","CDM","0250","RC","60687-695-11","NDC",,,"facility","inpatient","1.036281","UN",,"14.47","14.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFDINIR 300 MG PO CAPS","81000000","CDM","0250","RC","60687-699-11","NDC",,,"facility","inpatient","1.000000","UN",,"22.27","22.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPAFENONE HCL 150 MG PO TABS","81000000","CDM","0250","RC","60687-709-11","NDC",,,"facility","inpatient","5.571428","UN",,"12","12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXCARBAZEPINE 150 MG PO TABS","81000000","CDM","0250","RC","60687-711-11","NDC",,,"facility","inpatient","1.000000","UN",,"13.09","13.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL 30 MG PO TABS","81000000","CDM","0250","RC","60687-717-11","NDC",,,"facility","inpatient","1.197924","UN",,"9.37","9.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE 0.1 MG PO TABS","81000000","CDM","0250","RC","60687-721-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXCARBAZEPINE 300 MG PO TABS","81000000","CDM","0250","RC","60687-722-11","NDC",,,"facility","inpatient","1.266666","UN",,"14.96","14.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","81000000","CDM","0250","RC","60687-725-11","NDC",,,"facility","inpatient","1.125000","UN",,"20.9","20.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 30 MG PO CPEP","81000000","CDM","0250","RC","60687-734-11","NDC",,,"facility","inpatient","1.183486","UN",,"36.25","36.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCRALFATE 1 GM/10ML PO SUSP","81000000","CDM","0250","RC","60687-738-08","NDC",,,"facility","inpatient","10.000000","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 250 MG PO TABS","81000000","CDM","0250","RC","60687-742-11","NDC",,,"facility","inpatient","1.065813","UN",,"11.05","11.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LURASIDONE HCL 20 MG PO TABS","81000000","CDM","0250","RC","60687-747-11","NDC",,,"facility","inpatient","1.000000","UN",,"28.11","28.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE 2MG/ML ORAL LIQD (PEDIATRIC) SH","81000000","CDM","0250","RC","60687-760-40","NDC",,,"facility","inpatient","5.000000","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAMADOL HCL 50 MG PO TABS","81000000","CDM","0250","RC","60687-795-11","NDC",,,"facility","inpatient","1.071381","UN",,"38.05","38.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","81000000","CDM","0250","RC","60687-803-11","NDC",,,"facility","inpatient","1.000000","UN",,"42.03","42.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","60687-822-11","NDC",,,"facility","inpatient","1.009546","UN",,"8.40","8.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISOLONE ACETATE 1 % OP SUSP","81000000","CDM","0250","RC","60758-119-05","NDC",,,"facility","inpatient","6.880341","ML",,"264","264",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC TROMETHAMINE 0.4 % OP SOLN","81000000","CDM","0250","RC","60758-773-05","NDC",,,"facility","inpatient","15.000000","ML",,"364.55","364.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TIMOLOL MALEATE 0.5 % OP SOLN","81000000","CDM","0250","RC","60758-801-05","NDC",,,"facility","inpatient","5.000000","ML",,"42.64","42.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TIMOLOL MALEATE 0.25 % OP SOLN","81000000","CDM","0250","RC","60758-802-05","NDC",,,"facility","inpatient","5.952380","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOROMETHOLONE 0.1 % OP SUSP","81000000","CDM","0250","RC","60758-880-05","NDC",,,"facility","inpatient","5.000000","ML",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIOTHYRONINE SODIUM 5 MCG PO TABS","81000000","CDM","0250","RC","60793-115-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIOTHYRONINE SODIUM 25 MCG PO TABS","81000000","CDM","0250","RC","60793-116-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THROMBIN 5000 UNITS EX KIT","81000000","CDM","0250","RC","60793-205-05","NDC",,,"facility","inpatient","1","EA",,"404.16","404.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 1.000000 KIT"
"THROMBIN 5000 UNITS EX SOLR","81000000","CDM","0250","RC","60793-215-05","NDC",,,"facility","inpatient","1.000000","EA",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL 2 % OP SOLN","81000000","CDM","0250","RC","61314-019-10","NDC",,,"facility","inpatient","10.000000","ML",,"333.75","333.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC TROMETHAMINE 0.5 % OP SOLN","81000000","CDM","0250","RC","61314-126-05","NDC",,,"facility","inpatient","5.000000","ML",,"422","422",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PILOCARPINE HCL 1 % OP SOLN","81000000","CDM","0250","RC","61314-203-15","NDC",,,"facility","inpatient","15.000000","ML",,"394.26","394.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PILOCARPINE HCL 2 % OP SOLN","81000000","CDM","0250","RC","61314-204-15","NDC",,,"facility","inpatient","1","EA",,"403.26","403.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 900.000000 DROP"
"TIMOLOL MALEATE 0.5 % OP SOLN","81000000","CDM","0250","RC","61314-227-05","NDC",,,"facility","inpatient","5.000000","ML",,"81.65","81.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TROPICAMIDE 1 % OP SOLN","81000000","CDM","0250","RC","61314-355-01","NDC",,,"facility","inpatient","3.000000","ML",,"12.22","12.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPENTOLATE HCL 1 % OP SOLN","81000000","CDM","0250","RC","61314-396-01","NDC",,,"facility","inpatient","2.000000","ML",,"84","84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN","81000000","CDM","0250","RC","61314-628-10","NDC",,,"facility","inpatient","10.000000","ML",,"87.1","87.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP","81000000","CDM","0250","RC","61314-630-06","NDC",,,"facility","inpatient","5.000000","ML",,"220","220",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT","81000000","CDM","0250","RC","61314-631-36","NDC",,,"facility","inpatient","3.500000","GR",,"219.99","219.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISOLONE ACETATE 1 % OP SUSP","81000000","CDM","0250","RC","61314-637-05","NDC",,,"facility","inpatient","1","EA",,"274.33","274.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 79.687500 DROP"
"TOBRAMYCIN 9.1MG/ML OPHTHALMIC SOLN *COMPOUNDED* SH","81000000","CDM","0250","RC","61314-643-05","NDC",,,"facility","inpatient","25.000000","ML",,"102","102",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP","81000000","CDM","0250","RC","61314-647-25","NDC",,,"facility","inpatient","2.500000","ML",,"362.8","362.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 0.3 % OP SOLN","81000000","CDM","0250","RC","61314-656-25","NDC",,,"facility","inpatient","2.500000","ML",,"125.15","125.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","61442-202-01","NDC",,,"facility","inpatient","2.402985","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILVER SULFADIAZINE 1 % EX CREA","81000000","CDM","0250","RC","61570-131-55","NDC",,,"facility","inpatient","50.000000","GR",,"77.5","77.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS","81000000","CDM","0250","RC","61958-0401-1","NDC",,,"facility","inpatient","1.000000","UN",,"150.42","150.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMBRISENTAN 10 MG PO TABS","81000000","CDM","0250","RC","61958-0802-5","NDC",,,"facility","inpatient","1.000000","UN",,"1500","1500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RANOLAZINE ER 500 MG PO TB12","81000000","CDM","0250","RC","61958-1003-1","NDC",,,"facility","inpatient","1.000000","UN",,"32.89","32.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG PO TABS","81000000","CDM","0250","RC","61958-1901-1","NDC",,,"facility","inpatient","1.226415","UN",,"466.37","466.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITAB-RILPIVIR-TENOFOV AF 200-25-25 MG PO TABS","81000000","CDM","0250","RC","61958-2101-1","NDC",,,"facility","inpatient","1.000000","UN",,"434.78","434.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TENOFOVIR ALAFENAMIDE FUMARATE 25 MG PO TABS","81000000","CDM","0250","RC","61958-2301-1","NDC",,,"facility","inpatient","1.026519","UN",,"171.48","171.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG PO TABS","81000000","CDM","0250","RC","61958-2501-1","NDC",,,"facility","inpatient","1.103044","UN",,"469.51","469.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERMETHRIN 1 % EX LIQD","81000000","CDM","0250","RC","62011-0255-1","NDC",,,"facility","inpatient","59.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 10 MG/5ML PO SYRP","81000000","CDM","0250","RC","62135-502-47","NDC",,,"facility","inpatient","472.994944","ML",,"102.43","102.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 10 MG/5ML PO SYRP","81000000","CDM","0250","RC","62135-750-47","NDC",,,"facility","inpatient","526.879258","ML",,"49.16","49.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE MONONITRATE ER 30 MG PO TB24","81000000","CDM","0250","RC","62175-128-37","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOXETINE HCL 10 MG PO CAPS","81000000","CDM","0250","RC","62332-022-31","NDC",,,"facility","inpatient","1.000000","UN",,"14.38","14.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 0.25 MG PO TBDP","81000000","CDM","0250","RC","62332-365-06","NDC",,,"facility","inpatient","1.117527","UN",,"18.11","18.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 1 MG PO TBDP","81000000","CDM","0250","RC","62332-367-06","NDC",,,"facility","inpatient","1.096000","UN",,"38.64","38.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","81000000","CDM","0250","RC","62332-413-10","NDC",,,"facility","inpatient","1.000000","UN",,"56.72","56.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LURASIDONE HCL 40 MG PO TABS","81000000","CDM","0250","RC","62332-495-30","NDC",,,"facility","inpatient","1.000000","UN",,"113.50","113.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"UREA 15 G PO PACK","81000000","CDM","0250","RC","62530-00011","NDC",,,"facility","inpatient","1.067796","UN",,"23.76","23.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYETHYLENE GLYCOL 3350 17 G PO PACK","81000000","CDM","0250","RC","62559-157-10","NDC",,,"facility","inpatient","1.196103","UN",,"1.89","1.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 125 MG PO CAPS","81000000","CDM","0250","RC","62559-310-20","NDC",,,"facility","inpatient","1.037735","UN",,"310.04","310.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 125 MG PO CAPS","81000000","CDM","0250","RC","62559-390-20","NDC",,,"facility","inpatient","1.028605","UN",,"99.82","99.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 125 MG PO CAPS","81000000","CDM","0250","RC","62559-390-50","NDC",,,"facility","inpatient","1.058536","UN",,"99.94","99.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE (PERIANAL) 1 % EX CREA","81000000","CDM","0250","RC","62559-430-01","NDC",,,"facility","inpatient","32.064516","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR","81000000","CDM","0250","RC","62559-630-01","NDC",,,"facility","inpatient","100.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERBUTALINE SULFATE 5 MG PO TABS","81000000","CDM","0250","RC","62559-722-01","NDC",,,"facility","inpatient","1.000000","UN",,"36.24","36.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEXILETINE HCL 150 MG PO CAPS","81000000","CDM","0250","RC","62559-820-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.52","14.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEXILETINE HCL 200 MG PO CAPS","81000000","CDM","0250","RC","62559-821-01","NDC",,,"facility","inpatient","1.088888","UN",,"16.65","16.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12","81000000","CDM","0250","RC","62559-850-60","NDC",,,"facility","inpatient","1.000000","UN",,"45.95","45.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 250 MG PO CAPS","81000000","CDM","0250","RC","62584-235-01","NDC",,,"facility","inpatient","1.173913","UN",,"9.36","9.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 500 MG PO CAPS","81000000","CDM","0250","RC","62584-236-01","NDC",,,"facility","inpatient","1.000000","UN",,"19.16","19.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL TARTRATE 100 MG PO TABS","81000000","CDM","0250","RC","62584-267-01","NDC",,,"facility","inpatient","1.050552","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 300 MG PO TABS","81000000","CDM","0250","RC","62584-713-01","NDC",,,"facility","inpatient","1.960000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","62584-733-01","NDC",,,"facility","inpatient","1.078024","UN",,"8.93","8.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","62584-734-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXAZEPAM 15 MG PO CAPS","81000000","CDM","0250","RC","62584-813-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOLIC ACID 1 MG PO TABS","81000000","CDM","0250","RC","62584-897-01","NDC",,,"facility","inpatient","1.000000","UN",,"2.16","2.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 100 MG PO TABS","81000000","CDM","0250","RC","62584-988-01","NDC",,,"facility","inpatient","1.000000","UN",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 4 MG PO TBDP","81000000","CDM","0250","RC","62756-240-64","NDC",,,"facility","inpatient","1.437756","UN",,"72.23","72.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIOTHYRONINE SODIUM 5 MCG PO TABS","81000000","CDM","0250","RC","62756-589-88","NDC",,,"facility","inpatient","1.114285","UN",,"13.48","13.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIOTHYRONINE SODIUM 25 MCG PO TABS","81000000","CDM","0250","RC","62756-590-88","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DONEPEZIL HCL 5 MG PO TABS","81000000","CDM","0250","RC","62856-245-30","NDC",,,"facility","inpatient","1.000000","UN",,"80.98","80.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TALC 4 G PL AERP","81000000","CDM","0250","RC","63256-100-30","NDC",,,"facility","inpatient","1","EA",,"378","378",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 1.500000 CAN"
"OPIUM 10MG/ML (1%) PO TINC SH","81000000","CDM","0250","RC","63304-203-01","NDC",,,"facility","inpatient","128.056361","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN HCL 300 MG PO CAPS","81000000","CDM","0250","RC","63304-693-01","NDC",,,"facility","inpatient","1.000000","UN",,"20.44","20.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 4.2 % IV SOLN","81000000","CDM","0250","RC","63323-083-05","NDC",,,"facility","inpatient","6.696113","ML",,"76.34","76.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","63323-086-15","NDC",,,"facility","inpatient","15.000150","ML",,"84.77","84.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","63323-089-50","NDC",,,"facility","inpatient","50.000000","ML",,"169.98","169.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 4 MEQ/ML ORAL SOLUTION","81000000","CDM","0250","RC","63323-093-01","NDC",,,"facility","inpatient","30.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE 100 MG/100ML NS (MINIBAG)","81000000","CDM","0250","RC","63323-130-11","NDC",,,"facility","inpatient","1.061711","UN",,"209.76","209.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","63323-186-01","NDC",,,"facility","inpatient","11.452748","ML",,"69.35","69.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","63323-186-10","NDC",,,"facility","inpatient","10.000000","ML",,"52.5","52.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","63323-186-20","NDC",,,"facility","inpatient","24.091778","ML","PN","44.32","44.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"SODIUM CHLORIDE (PF) 0.9 % IJ SOLN","81000000","CDM","0250","RC","63323-186-20","NDC",,,"facility","inpatient","20.753843","ML",,"71.68","71.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 4 MEQ/ML ORAL SOLUTION","81000000","CDM","0250","RC","63323-187-30","NDC",,,"facility","inpatient","29.990843","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINERAL OIL LIGHT OIL","81000000","CDM","0250","RC","63323-254-10","NDC",,,"facility","inpatient","10.000000","ML",,"1.83","1.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN","81000000","CDM","0250","RC","63323-416-05","NDC",,,"facility","inpatient","5.000000","ML",,"97.5","97.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN","81000000","CDM","0250","RC","63323-417-10","NDC",,,"facility","inpatient","10.000000","ML",,"143.52","143.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE (PF) 0.375 % IJ SOLN","81000000","CDM","0250","RC","63323-460-37","NDC",,,"facility","inpatient","59.999856","ML",,"115.36","115.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","81000000","CDM","0250","RC","63323-462-37","NDC",,,"facility","inpatient","29.999871","ML",,"77.62","77.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","63323-482-01","NDC",,,"facility","inpatient","11.742919","ML",,"57.95","57.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","63323-482-17","NDC",,,"facility","inpatient","21.428571","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","63323-482-27","NDC",,,"facility","inpatient","12.500000","ML",,"69.07","69.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN","81000000","CDM","0250","RC","63323-483-27","NDC",,,"facility","inpatient","14.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1 %-1:200000 IJ SOLN","81000000","CDM","0250","RC","63323-487-07","NDC",,,"facility","inpatient","52.978610","ML",,"84.6","84.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 1 %-1:200000 IJ SOLN","81000000","CDM","0250","RC","63323-487-37","NDC",,,"facility","inpatient","29.999884","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN","81000000","CDM","0250","RC","63323-489-02","NDC",,,"facility","inpatient","20.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 200 MCG IV SOLR","81000000","CDM","0250","RC","63323-647-10","NDC",,,"facility","inpatient","1.000000","UN",,"1266.95","1266.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000000","CDM","0250","RC","63323-649-07","NDC",,,"facility","inpatient","1.057388","UN",,"535.77","535.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN SODIUM 1 MG IV SOLR","81000000","CDM","0250","RC","63323-659-03","NDC",,,"facility","inpatient","1.000000","UN",,"501.97","501.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL TARTRATE 5 MG/5ML IV SOLN","81000000","CDM","0250","RC","63323-660-05","NDC",,,"facility","inpatient","5.720452","ML",,"66.18","66.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % ORAL SOLN CUSTOM CREATE","81000000","CDM","0250","RC","63323-692-10","NDC",,,"facility","inpatient","10.000000","ML",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAT EMULSION FISH OIL BASE 20% IV EMUL (NEONATAL)","81000000","CDM","0250","RC","63323-820-00","NDC",,,"facility","inpatient","143.813387","ML",,"79.35","79.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAT EMULSION FISH OIL BASE 20% IV EMUL (NEONATAL)","81000000","CDM","0250","RC","63323-820-01","NDC",,,"facility","inpatient","100.721889","ML",,"77.22","77.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAT EMULSION FISH OIL BASE 20% IV EMUL (NEONATAL)","81000000","CDM","0250","RC","63323-820-04","NDC",,,"facility","inpatient","250.000000","ML",,"75.8","75.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM PHOSPHATES 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","63323-881-01","NDC",,,"facility","inpatient","15.593116","ML",,"134.90","134.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM PHOSPHATES 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","63323-881-16","NDC",,,"facility","inpatient","15.000150","ML",,"108.31","108.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM PHOSPHATE 3 MMOL/ML ORAL SOLUTION","81000000","CDM","0250","RC","63323-884-01","NDC",,,"facility","inpatient","5.409841","ML",,"139.30","139.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM PHOSPHATE 3 MMOL/ML ORAL SOLUTION","81000000","CDM","0250","RC","63323-884-06","NDC",,,"facility","inpatient","5.000000","ML",,"151.38","151.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG/5ML IV SOLN","81000000","CDM","0250","RC","63323-885-10","NDC",,,"facility","inpatient","5.000000","ML",,"573.55","573.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LURASIDONE HCL 20 MG PO TABS","81000000","CDM","0250","RC","63402-302-30","NDC",,,"facility","inpatient","1.000000","UN",,"170.24","170.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LURASIDONE HCL 40 MG PO TABS","81000000","CDM","0250","RC","63402-304-10","NDC",,,"facility","inpatient","1.000000","UN",,"161.57","161.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVALBUTEROL TARTRATE 45 MCG/ACT IN AERO","81000000","CDM","0250","RC","63402-510-01","NDC",,,"facility","inpatient","15.000000","GR",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICLOFENAC SODIUM 1 % EX GEL","81000000","CDM","0250","RC","63481-684-47","NDC",,,"facility","inpatient","128.571428","GR",,"324","324",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX PTCH","81000000","CDM","0250","RC","63481-687-06","NDC",,,"facility","inpatient","1.214689","UN",,"97.71","97.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 25 MG PO TABS","81000000","CDM","0250","RC","63629-1061-1","NDC",,,"facility","inpatient","1.024096","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN 25 MG PO CAPS","81000000","CDM","0250","RC","63629-1913-1","NDC",,,"facility","inpatient","1.000000","UN",,"8.96","8.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR","81000000","CDM","0250","RC","63629-2391-1","NDC",,,"facility","inpatient","100.000000","ML",,"63.48","63.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBETASOL PROPIONATE 0.05 % EX OINT","81000000","CDM","0250","RC","63629-2458-1","NDC",,,"facility","inpatient","15.000000","GR",,"56.16","56.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOPIDOGREL BISULFATE 75 MG PO TABS","81000000","CDM","0250","RC","63653-1171-1","NDC",,,"facility","inpatient","1","EA",,"23.28","23.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 1.206451 TAB"
"GELATIN ABSORBABLE 12-7 MM EX MISC","81000000","CDM","0250","RC","63713-01972","NDC",,,"facility","inpatient","12.322581","UN",,"37.59","37.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GELATIN ABSORBABLE 100 EX MISC","81000000","CDM","0250","RC","63713-01974","NDC",,,"facility","inpatient","6.558008","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERMETHRIN 1 % EX LIQD","81000000","CDM","0250","RC","63736-12002","NDC",,,"facility","inpatient","59.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERMETHRIN 1 % EX LIQD","81000000","CDM","0250","RC","63736-12003","NDC",,,"facility","inpatient","59.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","63739-008-33","NDC",,,"facility","inpatient","1.034985","UN",,"92.99","92.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 200 MG PO TABS","81000000","CDM","0250","RC","63739-051-10","NDC",,,"facility","inpatient","1.023503","UN",,"9.59","9.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALACYCLOVIR HCL 500 MG PO TABS","81000000","CDM","0250","RC","63739-077-10","NDC",,,"facility","inpatient","1.046345","UN",,"10.94","10.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIRTAZAPINE 15 MG PO TABS","81000000","CDM","0250","RC","63739-098-10","NDC",,,"facility","inpatient","1.128421","UN",,"12.15","12.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 300 MG PO TB24","81000000","CDM","0250","RC","63739-132-33","NDC",,,"facility","inpatient","1.051282","UN",,"15.24","15.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDODRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","63739-145-10","NDC",,,"facility","inpatient","1.027088","UN",,"8.72","8.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FERROUS SULFATE 300 (60 FE) MG/5ML PO SOLN","81000000","CDM","0250","RC","63739-157-70","NDC",,,"facility","inpatient","5.000000","ML",,"1.47","1.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 100 MG/ML PO SOLN","81000000","CDM","0250","RC","63739-158-32","NDC",,,"facility","inpatient","5.122167","ML",,"20.72","20.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/ML MT SUSP","81000000","CDM","0250","RC","63739-160-10","NDC",,,"facility","inpatient","5.063635","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLYETHYLENE GLYCOL 3350 17 G PO PACK","81000000","CDM","0250","RC","63739-198-61","NDC",,,"facility","inpatient","1.120982","UN",,"1.94","1.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMETHICONE 80 MG PO CHEW","81000000","CDM","0250","RC","63739-225-10","NDC",,,"facility","inpatient","1.102236","UN",,"1.77","1.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","63739-327-10","NDC",,,"facility","inpatient","1.029273","UN",,"7.82","7.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","63739-328-10","NDC",,,"facility","inpatient","1.042838","UN",,"13.93","13.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 20 MG PO TABS","81000000","CDM","0250","RC","63739-367-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAPROXEN 500 MG PO TABS","81000000","CDM","0250","RC","63739-403-10","NDC",,,"facility","inpatient","1.153846","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASPIRIN 81 MG PO CHEW","81000000","CDM","0250","RC","63739-434-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.07","10.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASPIRIN 81 MG PO CHEW","81000000","CDM","0250","RC","63739-434-02","NDC",,,"facility","inpatient","3.666666","UN",,"5.04","5.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 10 MG PO TABS","81000000","CDM","0250","RC","63739-479-10","NDC",,,"facility","inpatient","1.046296","UN",,"11.91","11.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","63739-483-10","NDC",,,"facility","inpatient","1.011560","UN",,"12.57","12.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","63739-486-10","NDC",,,"facility","inpatient","1.044896","UN",,"9.50","9.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 25 MG PO TABS","81000000","CDM","0250","RC","63739-544-10","NDC",,,"facility","inpatient","1.087811","UN",,"10.67","10.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 50 MG PO TABS","81000000","CDM","0250","RC","63739-545-10","NDC",,,"facility","inpatient","1.030534","UN",,"12.63","12.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 600 MG PO TABS","81000000","CDM","0250","RC","63739-560-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TAMSULOSIN HCL 0.4 MG PO CAPS","81000000","CDM","0250","RC","63739-567-10","NDC",,,"facility","inpatient","1.094333","UN",,"13.59","13.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMVASTATIN 10 MG PO TABS","81000000","CDM","0250","RC","63739-571-10","NDC",,,"facility","inpatient","2.077441","UN",,"10.32","10.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMVASTATIN 20 MG PO TABS","81000000","CDM","0250","RC","63739-572-10","NDC",,,"facility","inpatient","1.131045","UN",,"13.29","13.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMVASTATIN 40 MG PO TABS","81000000","CDM","0250","RC","63739-573-10","NDC",,,"facility","inpatient","1.039215","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 20 MG PO TABS","81000000","CDM","0250","RC","63739-645-10","NDC",,,"facility","inpatient","1.000000","UN","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FAMOTIDINE 20 MG PO TABS","81000000","CDM","0250","RC","63739-645-10","NDC",,,"facility","inpatient","1.071693","UN",,"1.93","1.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IBUPROFEN 400 MG PO TABS","81000000","CDM","0250","RC","63739-672-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.09","10.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 25 MG PO TABS","81000000","CDM","0250","RC","63739-673-10","NDC",,,"facility","inpatient","1.000000","UN",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 50 MG PO TABS","81000000","CDM","0250","RC","63739-686-10","NDC",,,"facility","inpatient","1.142146","UN",,"11.40","11.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 100 MG PO CAPS","81000000","CDM","0250","RC","63739-902-10","NDC",,,"facility","inpatient","1.042413","UN",,"10.78","10.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 300 MG PO CAPS","81000000","CDM","0250","RC","63739-903-10","NDC",,,"facility","inpatient","1.095891","UN",,"10.57","10.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PAROXETINE HCL 20 MG PO TABS","81000000","CDM","0250","RC","63739-963-10","NDC",,,"facility","inpatient","1.088397","UN",,"13.26","13.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG","81000000","CDM","0250","RC","63824-713-16","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IMIPRAMINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","64380-171-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.52","10.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS","81000000","CDM","0250","RC","64380-714-04","NDC",,,"facility","inpatient","1.000000","UN",,"120.89","120.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS","81000000","CDM","0250","RC","64380-761-11","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PEG 3350-KCL-NA BICARB-NACL 420 G PO SOLR","81000000","CDM","0250","RC","64380-769-21","NDC",,,"facility","inpatient","4000.000000","ML",,"216","216",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","81000000","CDM","0250","RC","64380-797-01","NDC",,,"facility","inpatient","1.727272","UN",,"56.72","56.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","81000000","CDM","0250","RC","64380-799-01","NDC",,,"facility","inpatient","1.108108","UN",,"61.83","61.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENALAPRIL MALEATE 10 MG PO TABS","81000000","CDM","0250","RC","64679-925-02","NDC",,,"facility","inpatient","1.000000","UN",,"12.13","12.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXLANSOPRAZOLE 60 MG PO CPDR","81000000","CDM","0250","RC","64764-175-30","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANSOPRAZOLE 15 MG PO TBDD","81000000","CDM","0250","RC","64764-543-11","NDC",,,"facility","inpatient","1.000000","UN",,"53.28","53.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"K PHOS MONO-SOD PHOS DI & MONO 155-852-130 MG PO TABS","81000000","CDM","0250","RC","64980-104-01","NDC",,,"facility","inpatient","1.034314","UN",,"10.20","10.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACIDOPHILUS PO TABS","81000000","CDM","0250","RC","64980-129-50","NDC",,,"facility","inpatient","1.169014","UN",,"1.99","1.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPYRIDAMOLE 75 MG PO TABS","81000000","CDM","0250","RC","64980-135-01","NDC",,,"facility","inpatient","1.000000","UN",,"16.84","16.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTINEX PO PACK","81000000","CDM","0250","RC","64980-146-98","NDC",,,"facility","inpatient","1.285714","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE (PERIANAL) 2.5 % EX CREA","81000000","CDM","0250","RC","64980-301-30","NDC",,,"facility","inpatient","30.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 1 MCG/ML PO SOLN","81000000","CDM","0250","RC","64980-447-15","NDC",,,"facility","inpatient","14.999296","ML",,"172.78","172.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOCARNITINE 1 GM/10ML PO SOLN","81000000","CDM","0250","RC","64980-503-12","NDC",,,"facility","inpatient","117.994100","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TIMOLOL MALEATE 0.5 % OP SOLN","81000000","CDM","0250","RC","64980-514-05","NDC",,,"facility","inpatient","5.723124","ML",,"83.60","83.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SEVELAMER CARBONATE 800 MG PO TABS","81000000","CDM","0250","RC","65162-058-27","NDC",,,"facility","inpatient","1.081218","UN",,"30.00","30.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BETHANECHOL CHLORIDE 5 MG PO TABS","81000000","CDM","0250","RC","65162-571-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAMADOL HCL 50 MG PO TABS","81000000","CDM","0250","RC","65162-627-11","NDC",,,"facility","inpatient","1.047619","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENAZOPYRIDINE HCL 100 MG PO TABS","81000000","CDM","0250","RC","65162-681-10","NDC",,,"facility","inpatient","1.060150","UN",,"1.75","1.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENAZOPYRIDINE HCL 200 MG PO TABS","81000000","CDM","0250","RC","65162-682-10","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","65162-705-88","NDC",,,"facility","inpatient","262.919284","ML",,"41.10","41.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX PTCH","81000000","CDM","0250","RC","65162-791-04","NDC",,,"facility","inpatient","1.233276","UN",,"46.54","46.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LURASIDONE HCL 40 MG PO TABS","81000000","CDM","0250","RC","65162-880-03","NDC",,,"facility","inpatient","1.000000","UN",,"158.05","158.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 40 MG/ML PO SUSR","81000000","CDM","0250","RC","65162-913-22","NDC",,,"facility","inpatient","75.000000","ML",,"665.54","665.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","65219-054-09","NDC",,,"facility","inpatient","16.701312","ML",,"145.14","145.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAT EMULSION 20% IV (NEONATAL)","81000000","CDM","0250","RC","65219-531-01","NDC",,,"facility","inpatient","100.863456","ML",,"78.01","78.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL","81000000","CDM","0250","RC","65219-533-01","NDC",,,"facility","inpatient","256.677796","ML",,"342.88","342.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR","81000000","CDM","0250","RC","65293-006-41","NDC",,,"facility","inpatient","1.067415","EA",,"412.59","412.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THROMBIN (RECOMBINANT) 20000 UNITS EX SOLR","81000000","CDM","0250","RC","65293-007-41","NDC",,,"facility","inpatient","5.160000","UN",,"1238.4","1238.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENADRYL/VISCOUS LIDOCAINE/MYLANTA (1:1:1) MOUTHWASH","81000000","CDM","0250","RC","65628-050-01","NDC",,,"facility","inpatient","263.720659","ML",,"51.64","51.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 50 MG/ML PO SOLR","81000000","CDM","0250","RC","65628-206-05","NDC",,,"facility","inpatient","153.374735","ML",,"31.79","31.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PEG-KCL-NACL-NASULF-NA ASC-C 100 G PO SOLR","81000000","CDM","0250","RC","65649-201-75","NDC",,,"facility","inpatient","1.105369","UN",,"316.03","316.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 40 MG/5ML PO SUSR","81000000","CDM","0250","RC","65649-211-24","NDC",,,"facility","inpatient","52.242564","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIFAXIMIN 200 MG PO TABS","81000000","CDM","0250","RC","65649-301-03","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIFAXIMIN 550 MG PO TABS","81000000","CDM","0250","RC","65649-303-03","NDC",,,"facility","inpatient","1.034849","UN",,"194.33","194.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROTHIAZIDE 250 MG/5ML PO SUSP","81000000","CDM","0250","RC","65649-311-12","NDC",,,"facility","inpatient","236.928751","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE (PERIANAL) 1 % EX CREA","81000000","CDM","0250","RC","65649-501-30","NDC",,,"facility","inpatient","28.400000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIRTAZAPINE 15 MG PO TBDP","81000000","CDM","0250","RC","65862-021-06","NDC",,,"facility","inpatient","1.274509","UN",,"14.72","14.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZIDOVUDINE 50 MG/5ML PO SYRP","81000000","CDM","0250","RC","65862-048-24","NDC",,,"facility","inpatient","240.066225","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EFAVIRENZ 600 MG PO TABS","81000000","CDM","0250","RC","65862-049-30","NDC",,,"facility","inpatient","1.000000","UN",,"111.79","111.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEVIRAPINE 50 MG/5ML PO SUSP","81000000","CDM","0250","RC","65862-057-24","NDC",,,"facility","inpatient","239.955357","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 500 MG PO TABS","81000000","CDM","0250","RC","65862-077-05","NDC",,,"facility","inpatient","1.227461","UN",,"25.83","25.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERBINAFINE HCL 250 MG PO TABS","81000000","CDM","0250","RC","65862-079-30","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUMATRIPTAN SUCCINATE 50 MG PO TABS","81000000","CDM","0250","RC","65862-147-36","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFDINIR 300 MG PO CAPS","81000000","CDM","0250","RC","65862-177-60","NDC",,,"facility","inpatient","1.000000","UN",,"28.09","28.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFDINIR 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","65862-219-01","NDC",,,"facility","inpatient","100.000000","ML",,"36.71","36.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 5 MG PO TABS","81000000","CDM","0250","RC","65862-373-01","NDC",,,"facility","inpatient","1.125000","UN",,"24.81","24.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 4 MG PO TBDP","81000000","CDM","0250","RC","65862-390-10","NDC",,,"facility","inpatient","1.133333","UN",,"81.74","81.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 8 MG PO TBDP","81000000","CDM","0250","RC","65862-391-10","NDC",,,"facility","inpatient","1.000000","UN","PN","111.4","111.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ONDANSETRON 8 MG PO TBDP","81000000","CDM","0250","RC","65862-391-10","NDC",,,"facility","inpatient","1.088328","UN",,"111.40","111.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS","81000000","CDM","0250","RC","65862-502-20","NDC",,,"facility","inpatient","1.040000","UN",,"20.61","20.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","81000000","CDM","0250","RC","65862-503-01","NDC",,,"facility","inpatient","1.000000","UN",,"27.23","27.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIOGLITAZONE HCL 15 MG PO TABS","81000000","CDM","0250","RC","65862-512-30","NDC",,,"facility","inpatient","1.000000","UN",,"38.54","38.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 250 MG PO TABS","81000000","CDM","0250","RC","65862-641-69","NDC",,,"facility","inpatient","1.000000","UN",,"34.63","34.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RITONAVIR 100 MG PO TABS","81000000","CDM","0250","RC","65862-687-30","NDC",,,"facility","inpatient","1.000000","UN",,"50.92","50.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZIPRASIDONE HCL 20 MG PO CAPS","81000000","CDM","0250","RC","65862-702-60","NDC",,,"facility","inpatient","1.000000","UN",,"49.3","49.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","65862-707-01","NDC",,,"facility","inpatient","113.996656","ML",,"29.06","29.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATAZANAVIR SULFATE 200 MG PO CAPS","81000000","CDM","0250","RC","65862-712-60","NDC",,,"facility","inpatient","1.000000","UN",,"83.40","83.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALGANCICLOVIR HCL 450 MG PO TABS","81000000","CDM","0250","RC","65862-753-60","NDC",,,"facility","inpatient","1.029629","UN",,"206.33","206.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRASUGREL HCL 10 MG PO TABS","81000000","CDM","0250","RC","65862-830-30","NDC",,,"facility","inpatient","1.027586","UN",,"58.82","58.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENTECAVIR 1 MG PO TABS","81000000","CDM","0250","RC","65862-842-30","NDC",,,"facility","inpatient","1.000000","UN",,"133.31","133.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE 10 G PO PACK","81000000","CDM","0250","RC","66220-719-30","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE-EPINEPHRINE 2 %-1:50000 IJ SOLN","81000000","CDM","0250","RC","66312-181-16","NDC",,,"facility","inpatient","1.700000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASPIRIN 325 MG PO TABS","81000000","CDM","0250","RC","66553-001-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.13","10.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASPIRIN 81 MG PO CHEW","81000000","CDM","0250","RC","66553-002-01","NDC",,,"facility","inpatient","3.666666","UN",,"2.59","2.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CARBONATE ANTACID 500 MG PO CHEW","81000000","CDM","0250","RC","66553-004-01","NDC",,,"facility","inpatient","1.068925","UN",,"1.37","1.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 650 MG PO TABS","81000000","CDM","0250","RC","66553-008-01","NDC",,,"facility","inpatient","1.040286","UN",,"1.17","1.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EZETIMIBE 10 MG PO TABS","81000000","CDM","0250","RC","66582-414-31","NDC",,,"facility","inpatient","1.000000","UN",,"55.2","55.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR","81000000","CDM","0250","RC","66685-1012-2","NDC",,,"facility","inpatient","1.000000","ML",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN","81000000","CDM","0250","RC","66689-023-50","NDC",,,"facility","inpatient","14.999984","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE 10 MG/5ML PO SOLN","81000000","CDM","0250","RC","66689-032-50","NDC",,,"facility","inpatient","5.000000","ML",,"30.17","30.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTULOSE 10 GM/15ML PO SOLN","81000000","CDM","0250","RC","66689-038-50","NDC",,,"facility","inpatient","30.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","81000000","CDM","0250","RC","66689-053-01","NDC",,,"facility","inpatient","31.849710","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATOVAQUONE 750 MG/5ML PO SUSP","81000000","CDM","0250","RC","66689-062-42","NDC",,,"facility","inpatient","5.000000","ML",,"187.5","187.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML PO ELIX","81000000","CDM","0250","RC","66689-063-10","NDC",,,"facility","inpatient","5.000000","ML",,"170.1","170.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 0.05 MG/ML PO SOLN","81000000","CDM","0250","RC","66689-327-02","NDC",,,"facility","inpatient","59.995200","ML",,"40.28","40.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","66689-401-50","NDC",,,"facility","inpatient","5.151164","ML",,"37.43","37.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCRALFATE 1 GM/10ML PO SUSP","81000000","CDM","0250","RC","66689-790-50","NDC",,,"facility","inpatient","10.347826","ML",,"56.04","56.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE CR 20 MEQ PO TBCR SH","81000000","CDM","0250","RC","66758-190-13","NDC",,,"facility","inpatient","1.000000","UN","PN","5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"POTASSIUM CHLORIDE CR 20 MEQ PO TBCR SH","81000000","CDM","0250","RC","66758-190-13","NDC",,,"facility","inpatient","1.287179","UN",,"10.16","10.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE PROPIONATE HFA 44 MCG/ACT IN AERO","81000000","CDM","0250","RC","66993-078-96","NDC",,,"facility","inpatient","12.831578","GR",,"901.87","901.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE PROPIONATE HFA 110 MCG/ACT IN AERO","81000000","CDM","0250","RC","66993-079-96","NDC",,,"facility","inpatient","13.684209","GR",,"1135","1135",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUTICASONE PROPIONATE HFA 220 MCG/ACT IN AERO","81000000","CDM","0250","RC","66993-080-96","NDC",,,"facility","inpatient","12.000000","GR",,"1454.65","1454.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALISKIREN FUMARATE 300 MG PO TABS","81000000","CDM","0250","RC","66993-142-30","NDC",,,"facility","inpatient","5.000000","UN",,"54.21","54.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLCHICINE 0.3MG PO PRE-SPLIT TABS SH","81000000","CDM","0250","RC","66993-165-02","NDC",,,"facility","inpatient","0.500000","UN",,"18.52","18.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANTHANUM CARBONATE 500 MG PO CHEW","81000000","CDM","0250","RC","66993-422-85","NDC",,,"facility","inpatient","1.184210","UN",,"40.65","40.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPAGLIFLOZIN PROPANEDIOL 5 MG PO TABS","81000000","CDM","0250","RC","66993-456-30","NDC",,,"facility","inpatient","1.000000","UN",,"88.5","88.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMTERENE 50 MG PO CAPS","81000000","CDM","0250","RC","66993-831-02","NDC",,,"facility","inpatient","1.000000","UN",,"47.70","47.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBAZAM 2.5 MG/ML PO SUSP","81000000","CDM","0250","RC","67386-313-21","NDC",,,"facility","inpatient","120.001949","ML",,"477.59","477.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DROXIDOPA 100 MG PO CAPS","81000000","CDM","0250","RC","67386-820-19","NDC",,,"facility","inpatient","1.000000","UN",,"146.20","146.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE HCL 50 MG/ML IJ SOLN","81000000","CDM","0250","RC","67457-001-10","NDC",,,"facility","inpatient","19.729729","ML",,"87.80","87.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"REMIFENTANIL HCL 1 MG IV SOLR","81000000","CDM","0250","RC","67457-198-03","NDC",,,"facility","inpatient","0.666579","UN",,"284.24","284.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"REMIFENTANIL HCL 2 MG IV SOLR","81000000","CDM","0250","RC","67457-198-05","NDC",,,"facility","inpatient","0.053610","UN",,"339.20","339.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE 100 MG/100ML NS (MINIBAG)","81000000","CDM","0250","RC","67457-437-10","NDC",,,"facility","inpatient","1.000000","UN",,"127.43","127.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN","81000000","CDM","0250","RC","67457-925-00","NDC",,,"facility","inpatient","111.111111","ML",,"639.6","639.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POVIDONE-IODINE 10 % EX SOLN","81000000","CDM","0250","RC","67618-150-04","NDC",,,"facility","inpatient","120.913580","ML",,"3.50","3.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POVIDONE-IODINE 7.5 % EX SOLN","81000000","CDM","0250","RC","67618-151-04","NDC",,,"facility","inpatient","118.063754","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORHEXIDINE GLUCONATE 4 % EX SOLN","81000000","CDM","0250","RC","67618-200-04","NDC",,,"facility","inpatient","1534.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETHIODIZED OIL 480 MG/ML IJ OIL","81000000","CDM","0250","RC","67684-1901-1","NDC",,,"facility","inpatient","10.000000","ML",,"2940.67","2940.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETHIODIZED OIL 480 MG/ML IJ OIL","81000000","CDM","0250","RC","67684-1901-2","NDC",,,"facility","inpatient","10.000000","ML",,"4112.64","4112.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILVER SULFADIAZINE 1 % EX CREA","81000000","CDM","0250","RC","67877-124-05","NDC",,,"facility","inpatient","50.000000","GR",,"75.5","75.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILVER SULFADIAZINE 1 % EX CREA","81000000","CDM","0250","RC","67877-124-40","NDC",,,"facility","inpatient","400.000000","GR",,"324","324",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TEMAZEPAM 15 MG PO CAPS","81000000","CDM","0250","RC","67877-146-01","NDC",,,"facility","inpatient","1.000000","UN",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMLODIPINE BESYLATE 2.5 MG PO TABS","81000000","CDM","0250","RC","67877-197-90","NDC",,,"facility","inpatient","1.036036","UN",,"12.67","12.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","81000000","CDM","0250","RC","67877-251-80","NDC",,,"facility","inpatient","80.000000","GR",,"72.8","72.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RILUZOLE 50 MG PO TABS","81000000","CDM","0250","RC","67877-286-60","NDC",,,"facility","inpatient","1.000000","UN",,"110.82","110.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINEZOLID 600 MG PO TABS","81000000","CDM","0250","RC","67877-419-33","NDC",,,"facility","inpatient","1.016150","UN",,"550.99","550.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 2 MG PO TABS","81000000","CDM","0250","RC","67877-430-03","NDC",,,"facility","inpatient","1.000000","UN",,"89.01","89.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE 20 MG PO TABS","81000000","CDM","0250","RC","67877-434-03","NDC",,,"facility","inpatient","1.000000","UN",,"135.04","135.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFDINIR 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","67877-548-98","NDC",,,"facility","inpatient","59.998781","ML",,"44.93","44.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFPODOXIME PROXETIL 200 MG PO TABS","81000000","CDM","0250","RC","67877-879-20","NDC",,,"facility","inpatient","11.000000","UN",,"46.35","46.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS","81000000","CDM","0250","RC","68001-001-00","NDC",,,"facility","inpatient","1.000000","UN",,"15.60","15.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE 0.2 MG PO TABS","81000000","CDM","0250","RC","68001-575-00","NDC",,,"facility","inpatient","1.000000","UN",,"18.42","18.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OMEPRAZOLE-SODIUM BICARBONATE 20-1680 MG PO PACK","81000000","CDM","0250","RC","68012-052-30","NDC",,,"facility","inpatient","1","EA",,"396.82","396.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 1.000000 PACKET"
"ABACAVIR SULFATE 300 MG PO TABS","81000000","CDM","0250","RC","68084-021-21","NDC",,,"facility","inpatient","1.000000","UN",,"46.72","46.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACLOFEN 5MG/ML ORAL SUSP *COMPOUND* SH","81000000","CDM","0250","RC","68084-039-01","NDC",,,"facility","inpatient","1.000000","ML",,"5.83","5.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PAROXETINE HCL 20 MG PO TABS","81000000","CDM","0250","RC","68084-045-01","NDC",,,"facility","inpatient","1.266666","UN",,"15.34","15.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 250 MG PO TABS","81000000","CDM","0250","RC","68084-069-01","NDC",,,"facility","inpatient","1.000000","UN",,"28.76","28.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN HCL 500 MG PO TABS","81000000","CDM","0250","RC","68084-070-01","NDC",,,"facility","inpatient","1.084210","UN",,"16.83","16.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRETINOIN 10 MG PO CAPS","81000000","CDM","0250","RC","68084-075-21","NDC",,,"facility","inpatient","1.533333","UN",,"151.67","151.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 10 MG PO TABS","81000000","CDM","0250","RC","68084-082-01","NDC",,,"facility","inpatient","1.000000","UN",,"11.75","11.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 20 MG PO TABS","81000000","CDM","0250","RC","68084-083-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA 25-100 MG PO TABS","81000000","CDM","0250","RC","68084-093-01","NDC",,,"facility","inpatient","1.237623","UN",,"9.17","9.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 10 MG PO TABS","81000000","CDM","0250","RC","68084-097-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR 800 MG PO TABS","81000000","CDM","0250","RC","68084-109-01","NDC",,,"facility","inpatient","1.195121","UN",,"20.20","20.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIRTAZAPINE 30 MG PO TABS","81000000","CDM","0250","RC","68084-120-01","NDC",,,"facility","inpatient","1.615384","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE ER 15 MG PO TBCR","81000000","CDM","0250","RC","68084-157-01","NDC",,,"facility","inpatient","1.123966","UN",,"32.51","32.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 30 MG PO TABS","81000000","CDM","0250","RC","68084-185-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 5 MG PO TABS","81000000","CDM","0250","RC","68084-196-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRIMIDONE 50 MG PO TABS","81000000","CDM","0250","RC","68084-202-01","NDC",,,"facility","inpatient","1.000000","UN",,"10.26","10.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINOXIDIL 2.5 MG PO TABS","81000000","CDM","0250","RC","68084-204-01","NDC",,,"facility","inpatient","1.075471","UN",,"12.01","12.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINOXIDIL 10 MG PO TABS","81000000","CDM","0250","RC","68084-205-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZONATATE 100 MG PO CAPS","81000000","CDM","0250","RC","68084-214-11","NDC",,,"facility","inpatient","1.017241","UN",,"14.40","14.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALACYCLOVIR HCL 500 MG PO TABS","81000000","CDM","0250","RC","68084-215-01","NDC",,,"facility","inpatient","1.000000","UN",,"21.85","21.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN HCL 300 MG PO CAPS","81000000","CDM","0250","RC","68084-244-01","NDC",,,"facility","inpatient","1.190476","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORATADINE 10 MG PO TABS","81000000","CDM","0250","RC","68084-248-01","NDC",,,"facility","inpatient","1.000000","UN","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LORATADINE 10 MG PO TABS","81000000","CDM","0250","RC","68084-248-01","NDC",,,"facility","inpatient","1.320000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 300 MG PO TB24","81000000","CDM","0250","RC","68084-252-21","NDC",,,"facility","inpatient","1.097859","UN",,"26.12","26.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","68084-253-01","NDC",,,"facility","inpatient","1.000000","UN",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","68084-254-01","NDC",,,"facility","inpatient","1.266666","UN",,"9.63","9.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 0.25 MG PO TABS","81000000","CDM","0250","RC","68084-270-01","NDC",,,"facility","inpatient","21.000000","UN",,"21.41","21.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RISPERIDONE 1 MG PO TABS","81000000","CDM","0250","RC","68084-272-01","NDC",,,"facility","inpatient","1.835820","UN",,"24.98","24.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETHAMBUTOL HCL 400 MG PO TABS","81000000","CDM","0250","RC","68084-280-01","NDC",,,"facility","inpatient","1.075039","UN",,"8.65","8.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR","81000000","CDM","0250","RC","68084-281-01","NDC",,,"facility","inpatient","1.050069","UN",,"10.36","10.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR","81000000","CDM","0250","RC","68084-282-01","NDC",,,"facility","inpatient","1.033333","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYUREA 500 MG PO CAPS","81000000","CDM","0250","RC","68084-284-01","NDC",,,"facility","inpatient","1.029197","UN",,"25.04","25.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUDROCORTISONE ACETATE 0.1 MG PO TABS","81000000","CDM","0250","RC","68084-288-01","NDC",,,"facility","inpatient","1.017057","UN",,"13.81","13.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TAMSULOSIN HCL 0.4 MG PO CAPS","81000000","CDM","0250","RC","68084-299-01","NDC",,,"facility","inpatient","1.025157","UN",,"23.18","23.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM ER 250 MG PO TB24","81000000","CDM","0250","RC","68084-310-01","NDC",,,"facility","inpatient","9.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM 125 MG PO CSDR","81000000","CDM","0250","RC","68084-313-01","NDC",,,"facility","inpatient","1.045801","UN",,"8.09","8.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE 100 MG PO TABS","81000000","CDM","0250","RC","68084-319-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOPIRAMATE 25 MG PO TABS","81000000","CDM","0250","RC","68084-342-01","NDC",,,"facility","inpatient","1.063116","UN",,"13.12","13.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOPIRAMATE 100 MG PO TABS","81000000","CDM","0250","RC","68084-344-01","NDC",,,"facility","inpatient","1.000000","UN",,"32.55","32.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 25 MG PO TABS","81000000","CDM","0250","RC","68084-346-01","NDC",,,"facility","inpatient","1.322580","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 50 MG PO TABS","81000000","CDM","0250","RC","68084-347-01","NDC",,,"facility","inpatient","1.071197","UN",,"13.38","13.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOSARTAN POTASSIUM 100 MG PO TABS","81000000","CDM","0250","RC","68084-348-01","NDC",,,"facility","inpatient","5.000000","UN",,"16.92","16.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 5 MG PO TABS","81000000","CDM","0250","RC","68084-354-01","NDC",,,"facility","inpatient","1.077139","UN",,"26.63","26.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS","81000000","CDM","0250","RC","68084-376-01","NDC",,,"facility","inpatient","1.032520","UN",,"7.19","7.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZTROPINE MESYLATE 0.5 MG PO TABS","81000000","CDM","0250","RC","68084-381-01","NDC",,,"facility","inpatient","1.080000","UN",,"14.17","14.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZTROPINE MESYLATE 1 MG PO TABS","81000000","CDM","0250","RC","68084-388-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM ER 500 MG PO TB24","81000000","CDM","0250","RC","68084-415-01","NDC",,,"facility","inpatient","1.193548","UN",,"19.38","19.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","68084-447-01","NDC",,,"facility","inpatient","1.034042","UN",,"11.31","11.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MECLIZINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","68084-491-01","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMVASTATIN 20 MG PO TABS","81000000","CDM","0250","RC","68084-512-01","NDC",,,"facility","inpatient","1.000000","UN",,"18.45","18.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TORSEMIDE 20 MG PO TABS","81000000","CDM","0250","RC","68084-539-01","NDC",,,"facility","inpatient","1.000000","UN",,"6.42","6.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24","81000000","CDM","0250","RC","68084-597-01","NDC",,,"facility","inpatient","1.074074","UN",,"12.60","12.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE 0.2 MG PO TABS","81000000","CDM","0250","RC","68084-604-21","NDC",,,"facility","inpatient","1.000000","UN",,"15.23","15.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 10 MG PO TABS","81000000","CDM","0250","RC","68084-617-01","NDC",,,"facility","inpatient","1.000000","UN",,"23.76","23.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESCITALOPRAM OXALATE 20 MG PO TABS","81000000","CDM","0250","RC","68084-618-01","NDC",,,"facility","inpatient","1.000000","UN",,"21.83","21.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LITHIUM CARBONATE ER 300 MG PO TBCR","81000000","CDM","0250","RC","68084-640-01","NDC",,,"facility","inpatient","1.571428","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SOTALOL HCL 80 MG PO TABS","81000000","CDM","0250","RC","68084-654-01","NDC",,,"facility","inpatient","1.089171","UN",,"11.57","11.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LITHIUM CARBONATE ER 450 MG PO TBCR","81000000","CDM","0250","RC","68084-655-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DULOXETINE HCL 60 MG PO CPEP","81000000","CDM","0250","RC","68084-692-01","NDC",,,"facility","inpatient","1.000000","UN",,"42.35","42.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL ER 37.5 MG PO CP24","81000000","CDM","0250","RC","68084-698-01","NDC",,,"facility","inpatient","1.053097","UN",,"19.28","19.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL ER 75 MG PO CP24","81000000","CDM","0250","RC","68084-709-01","NDC",,,"facility","inpatient","1.197044","UN",,"23.00","23.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS","81000000","CDM","0250","RC","68084-710-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL ER 150 MG PO CP24","81000000","CDM","0250","RC","68084-713-01","NDC",,,"facility","inpatient","1.145675","UN",,"25.09","25.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOBENZAPRINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","68084-753-25","NDC",,,"facility","inpatient","1.000000","UN",,"8.87","8.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GABAPENTIN 400 MG PO CAPS","81000000","CDM","0250","RC","68084-774-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIVALPROEX SODIUM 250 MG PO TBEC","81000000","CDM","0250","RC","68084-776-01","NDC",,,"facility","inpatient","1.000000","UN",,"9.69","9.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOMIPRAMINE HCL 25 MG PO CAPS","81000000","CDM","0250","RC","68084-790-25","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAMADOL HCL 50 MG PO TABS","81000000","CDM","0250","RC","68084-808-01","NDC",,,"facility","inpatient","1.067432","UN",,"38.26","38.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","81000000","CDM","0250","RC","68084-813-09","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPHENIDATE HCL 10 MG PO TABS","81000000","CDM","0250","RC","68084-823-21","NDC",,,"facility","inpatient","1.000000","UN",,"20","20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL 37.5 MG PO TABS","81000000","CDM","0250","RC","68084-844-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXCARBAZEPINE 300 MG PO TABS","81000000","CDM","0250","RC","68084-853-01","NDC",,,"facility","inpatient","3.000000","UN",,"15.14","15.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VENLAFAXINE HCL 75 MG PO TABS","81000000","CDM","0250","RC","68084-856-01","NDC",,,"facility","inpatient","1.000000","UN",,"13.21","13.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 250 MG PO TABS","81000000","CDM","0250","RC","68084-859-01","NDC",,,"facility","inpatient","1.000000","UN",,"7.62","7.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MONTELUKAST SODIUM 10 MG PO TABS","81000000","CDM","0250","RC","68084-875-01","NDC",,,"facility","inpatient","1.000000","UN",,"30.28","30.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","81000000","CDM","0250","RC","68084-895-01","NDC",,,"facility","inpatient","1.000000","UN","PN","40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"VENLAFAXINE HCL 25 MG PO TABS","81000000","CDM","0250","RC","68084-896-25","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PILOCARPINE HCL 5 MG PO TABS","81000000","CDM","0250","RC","68084-928-25","NDC",,,"facility","inpatient","1.000000","UN",,"16.5","16.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPYLTHIOURACIL 50 MG PO TABS","81000000","CDM","0250","RC","68084-964-25","NDC",,,"facility","inpatient","1.000000","UN",,"14.03","14.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CARBONATE ANTACID 500 MG PO CHEW","81000000","CDM","0250","RC","68084-988-32","NDC",,,"facility","inpatient","1.073059","UN",,"1.52","1.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAZOSIN HCL 1 MG PO CAPS","81000000","CDM","0250","RC","68084-996-01","NDC",,,"facility","inpatient","1.100000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE 2MG/ML ORAL LIQD (PEDIATRIC) SH","81000000","CDM","0250","RC","68094-001-62","NDC",,,"facility","inpatient","5.000000","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","81000000","CDM","0250","RC","68094-024-59","NDC",,,"facility","inpatient","10.977278","ML",,"1.01","1.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCRALFATE 1 GM/10ML PO SUSP","81000000","CDM","0250","RC","68094-043-59","NDC",,,"facility","inpatient","10.000000","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 3 MG PO TABS","81000000","CDM","0250","RC","68094-110-59","NDC",,,"facility","inpatient","1.067510","UN",,"1.96","1.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXCARBAZEPINE 300 MG/5ML PO SUSP","81000000","CDM","0250","RC","68094-123-59","NDC",,,"facility","inpatient","5.000000","ML",,"56.68","56.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LOPERAMIDE HCL 1 MG/7.5ML PO SOLN","81000000","CDM","0250","RC","68094-129-62","NDC",,,"facility","inpatient","15.147239","ML",,"17.45","17.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEGESTROL ACETATE 400 MG/10ML PO SUSP","81000000","CDM","0250","RC","68094-174-59","NDC",,,"facility","inpatient","20.000000","ML",,"44.93","44.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALPROATE SODIUM 250 MG/5ML PO SOLN","81000000","CDM","0250","RC","68094-193-62","NDC",,,"facility","inpatient","5.000000","ML",,"4.10","4.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 160 MG/5ML PO SUSP (PEDIATRIC)","81000000","CDM","0250","RC","68094-587-62","NDC",,,"facility","inpatient","5.000000","ML",,"10.4","10.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/ML MT SUSP","81000000","CDM","0250","RC","68094-599-61","NDC",,,"facility","inpatient","5.242424","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALPROATE SODIUM 250 MG/5ML PO SOLN","81000000","CDM","0250","RC","68094-701-62","NDC",,,"facility","inpatient","50.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 2 MG/ML PO SYRP","81000000","CDM","0250","RC","68094-764-59","NDC",,,"facility","inpatient","5.000000","ML",,"36.80","36.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALTREXONE HCL 50 MG PO TABS","81000000","CDM","0250","RC","68094-853-62","NDC",,,"facility","inpatient","1.000000","UN",,"15.05","15.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 8 MG/ML PO SOLN","81000000","CDM","0250","RC","68094-867-59","NDC",,,"facility","inpatient","5.071258","ML",,"14.90","14.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MULTIVITAMINS+MINERALS PO TABS SH","81000000","CDM","0250","RC","68176-00015","NDC",,,"facility","inpatient","1.054514","UN",,"11.78","11.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","68180-124-01","NDC",,,"facility","inpatient","100.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 125 MG PO CAPS","81000000","CDM","0250","RC","68180-166-11","NDC",,,"facility","inpatient","1.046057","UN",,"99.48","99.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 250 MG PO CAPS","81000000","CDM","0250","RC","68180-167-11","NDC",,,"facility","inpatient","1.000000","UN",,"173.15","173.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETHAMBUTOL HCL 100 MG PO TABS","81000000","CDM","0250","RC","68180-280-01","NDC",,,"facility","inpatient","1.333333","UN",,"9","9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFUROXIME AXETIL 500 MG PO TABS","81000000","CDM","0250","RC","68180-303-20","NDC",,,"facility","inpatient","1.000000","UN",,"44.09","44.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 150 MG PO TB24","81000000","CDM","0250","RC","68180-319-09","NDC",,,"facility","inpatient","1.066298","UN",,"24.83","24.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 300 MG PO TB24","81000000","CDM","0250","RC","68180-320-06","NDC",,,"facility","inpatient","1.000000","UN",,"26.22","26.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","68180-441-01","NDC",,,"facility","inpatient","100.000000","ML",,"30.15","30.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEPHALEXIN 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","68180-441-02","NDC",,,"facility","inpatient","200.000000","ML",,"28.95","28.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"QUETIAPINE FUMARATE 25 MG PO TABS","81000000","CDM","0250","RC","68180-445-01","NDC",,,"facility","inpatient","1.000000","UN",,"20.00","20.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXYCYCLINE MONOHYDRATE 25 MG/5ML PO SUSR","81000000","CDM","0250","RC","68180-657-01","NDC",,,"facility","inpatient","54.432680","ML",,"100.83","100.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR","81000000","CDM","0250","RC","68180-678-01","NDC",,,"facility","inpatient","60.001057","ML",,"84.39","84.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFDINIR 300 MG PO CAPS","81000000","CDM","0250","RC","68180-711-60","NDC",,,"facility","inpatient","1.000000","UN",,"28.13","28.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFDINIR 250 MG/5ML PO SUSR","81000000","CDM","0250","RC","68180-723-05","NDC",,,"facility","inpatient","100.000000","ML",,"30.87","30.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANTHANUM CARBONATE 500 MG PO CHEW","81000000","CDM","0250","RC","68180-819-52","NDC",,,"facility","inpatient","1.000000","UN",,"40.10","40.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","81000000","CDM","0250","RC","68180-963-01","NDC",,,"facility","inpatient","8.500000","GR",,"370.09","370.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LISINOPRIL 10 MG PO TABS","81000000","CDM","0250","RC","68180-980-01","NDC",,,"facility","inpatient","1.048192","UN",,"9.18","9.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX POWD","81000000","CDM","0250","RC","68308-152-15","NDC",,,"facility","inpatient","17.131147","GR",,"109.73","109.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 3.125 MG PO TABS","81000000","CDM","0250","RC","68382-092-01","NDC",,,"facility","inpatient","1.028571","UN",,"13.34","13.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 12.5 MG PO TABS","81000000","CDM","0250","RC","68382-094-01","NDC",,,"facility","inpatient","1.104672","UN",,"13.39","13.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 40 MG PO TABS","81000000","CDM","0250","RC","68382-251-16","NDC",,,"facility","inpatient","1.037296","UN",,"30.17","30.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPROPION HCL ER (XL) 300 MG PO TB24","81000000","CDM","0250","RC","68382-354-06","NDC",,,"facility","inpatient","1.000000","UN",,"34.61","34.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESALAMINE 800 MG PO TBEC","81000000","CDM","0250","RC","68382-435-28","NDC",,,"facility","inpatient","1.000000","UN",,"51.01","51.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESALAMINE ER 0.375 G PO CP24","81000000","CDM","0250","RC","68382-452-19","NDC",,,"facility","inpatient","8.000000","UN",,"5.28","5.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANSOPRAZOLE 15 MG PO TBDD","81000000","CDM","0250","RC","68382-771-30","NDC",,,"facility","inpatient","1.101095","UN",,"50.82","50.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANSOPRAZOLE 30 MG PO TBDD","81000000","CDM","0250","RC","68382-772-30","NDC",,,"facility","inpatient","1.051063","UN",,"62.51","62.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRAZODONE HCL 50 MG PO TABS","81000000","CDM","0250","RC","68382-805-01","NDC",,,"facility","inpatient","1.087431","UN",,"12.75","12.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXCARBAZEPINE 150 MG PO TABS","81000000","CDM","0250","RC","68462-137-01","NDC",,,"facility","inpatient","1.342857","UN",,"8.35","8.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON 8 MG PO TBDP","81000000","CDM","0250","RC","68462-158-40","NDC",,,"facility","inpatient","7.000000","UN",,"115.49","115.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MUPIROCIN 2 % EX OINT","81000000","CDM","0250","RC","68462-180-22","NDC",,,"facility","inpatient","23.833333","GR",,"213.73","213.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LITHIUM CARBONATE 600 MG PO CAPS","81000000","CDM","0250","RC","68462-222-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE 5 MG PO CHEW","81000000","CDM","0250","RC","68462-228-01","NDC",,,"facility","inpatient","2.641025","UN",,"14.88","14.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LAMOTRIGINE 25 MG PO CHEW","81000000","CDM","0250","RC","68462-229-01","NDC",,,"facility","inpatient","1.000000","UN",,"13.75","13.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROPINIROLE HCL 2 MG PO TABS","81000000","CDM","0250","RC","68462-256-01","NDC",,,"facility","inpatient","1.941176","UN",,"14.28","14.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL ER 120 MG PO TBCR","81000000","CDM","0250","RC","68462-292-01","NDC",,,"facility","inpatient","1.181818","UN",,"13.76","13.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS","81000000","CDM","0250","RC","68462-330-90","NDC",,,"facility","inpatient","1.121212","UN",,"18.38","18.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS","81000000","CDM","0250","RC","68462-331-90","NDC",,,"facility","inpatient","1.000000","UN",,"18.37","18.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.5 MG PO TABS","81000000","CDM","0250","RC","68462-332-90","NDC",,,"facility","inpatient","1.000000","UN",,"17.85","17.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS","81000000","CDM","0250","RC","68462-333-90","NDC",,,"facility","inpatient","1.000000","UN",,"18.38","18.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12","81000000","CDM","0250","RC","68462-405-60","NDC",,,"facility","inpatient","1.222222","UN",,"45.95","45.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG SL SUBL","81000000","CDM","0250","RC","68462-639-25","NDC",,,"facility","inpatient","28.934426","UN",,"128.38","128.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RASAGILINE MESYLATE 1 MG PO TABS","81000000","CDM","0250","RC","68546-229-56","NDC",,,"facility","inpatient","1.000000","UN",,"125.44","125.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISOSORBIDE DINITRATE 40 MG PO TABS","81000000","CDM","0250","RC","68682-192-01","NDC",,,"facility","inpatient","1.000000","UN",,"76.94","76.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PEG-KCL-NACL-NASULF-NA ASC-C 100 G PO SOLR","81000000","CDM","0250","RC","68682-201-75","NDC",,,"facility","inpatient","1.306944","UN",,"239.61","239.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BRILLIANT BLUE G 0.025 % IO SOSY","81000000","CDM","0250","RC","68803-722-25","NDC",,,"facility","inpatient","0.541228","ML",,"961.97","961.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOPIRAMATE 50 MG PO TABS","81000000","CDM","0250","RC","69097-123-03","NDC",,,"facility","inpatient","1.000000","UN",,"25.00","25.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALENDRONATE SODIUM 70 MG PO TABS","81000000","CDM","0250","RC","69097-224-16","NDC",,,"facility","inpatient","1.571428","UN",,"81.95","81.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBENDAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","69097-237-72","NDC",,,"facility","inpatient","1.000000","UN",,"686.72","686.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ABACAVIR SULFATE-LAMIVUDINE 600-300 MG PO TABS","81000000","CDM","0250","RC","69097-362-02","NDC",,,"facility","inpatient","1.800000","UN",,"139.51","139.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOSFOMYCIN TROMETHAMINE 3 G PO PACK","81000000","CDM","0250","RC","69097-579-67","NDC",,,"facility","inpatient","1.000000","UN",,"301.2","301.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE 200 MG PO CAPS","81000000","CDM","0250","RC","69097-642-02","NDC",,,"facility","inpatient","1.000000","UN",,"77.25","77.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10 MG PO TABS","81000000","CDM","0250","RC","69230-326-30","NDC",,,"facility","inpatient","1.000000","UN",,"1.58","1.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETHACRYNIC ACID 25 MG PO TABS","81000000","CDM","0250","RC","69238-1126-1","NDC",,,"facility","inpatient","1.142857","UN",,"72.58","72.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE 2 MG PO TABS","81000000","CDM","0250","RC","69238-1344-1","NDC",,,"facility","inpatient","1.000000","UN",,"27.5","27.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 2 MG PO TABS","81000000","CDM","0250","RC","69238-1491-1","NDC",,,"facility","inpatient","1.045977","UN",,"14.66","14.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5ML PO SUSR","81000000","CDM","0250","RC","69238-1504-2","NDC",,,"facility","inpatient","113.446843","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLOBETASOL PROPIONATE 0.05 % EX CREA","81000000","CDM","0250","RC","69238-1532-5","NDC",,,"facility","inpatient","15.000000","GR",,"512.94","512.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLERGONOVINE MALEATE 0.2 MG PO TABS","81000000","CDM","0250","RC","69238-1605-2","NDC",,,"facility","inpatient","1.029411","UN",,"201.69","201.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLERGONOVINE MALEATE 0.2 MG PO TABS","81000000","CDM","0250","RC","69238-1605-8","NDC",,,"facility","inpatient","1.000000","UN",,"201.57","201.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PILOCARPINE HCL 1 % OP SOLN","81000000","CDM","0250","RC","69238-1745-8","NDC",,,"facility","inpatient","15.000000","ML",,"394.26","394.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 25 MG/5ML PO SUSP","81000000","CDM","0250","RC","69238-2027-8","NDC",,,"facility","inpatient","117.999796","ML",,"323.86","323.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 10 MG PO TABS","81000000","CDM","0250","RC","69238-2077-1","NDC",,,"facility","inpatient","1.594285","UN",,"11.45","11.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 60 MG PO TABS","81000000","CDM","0250","RC","69238-2080-1","NDC",,,"facility","inpatient","2.333333","UN",,"13.19","13.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENALAPRIL 1MG/ML ORAL LIQD (PEDIATRIC) SH","81000000","CDM","0250","RC","69238-2141-7","NDC",,,"facility","inpatient","1.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOLAZONE 5 MG PO TABS","81000000","CDM","0250","RC","69292-564-01","NDC",,,"facility","inpatient","1.000000","UN",,"15.86","15.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOLAZONE 10 MG PO TABS","81000000","CDM","0250","RC","69292-566-01","NDC",,,"facility","inpatient","1.000000","UN",,"19.29","19.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 0.05 MG/ML PO SOLN","81000000","CDM","0250","RC","69292-605-60","NDC",,,"facility","inpatient","60.001371","ML",,"64.79","64.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLURBIPROFEN SODIUM 0.03 % OP SOLN","81000000","CDM","0250","RC","69292-722-25","NDC",,,"facility","inpatient","2.745398","ML",,"216","216",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NYSTATIN 100000 UNIT/GM EX POWD","81000000","CDM","0250","RC","69315-306-15","NDC",,,"facility","inpatient","16.132075","GR",,"116.4","116.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE (PERIANAL) 2.5 % EX CREA","81000000","CDM","0250","RC","69315-312-28","NDC",,,"facility","inpatient","28.000070","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 0.5 MG PO TABS","81000000","CDM","0250","RC","69315-904-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 1 MG PO TABS","81000000","CDM","0250","RC","69315-905-01","NDC",,,"facility","inpatient","1.000000","UN",,"20.87","20.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 1 MG PO TABS","81000000","CDM","0250","RC","69315-905-05","NDC",,,"facility","inpatient","1.153409","UN",,"33.29","33.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS","81000000","CDM","0250","RC","69315-910-01","NDC",,,"facility","inpatient","1.000000","UN",,"26.67","26.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN","81000000","CDM","0250","RC","69339-138-15","NDC",,,"facility","inpatient","15.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","81000000","CDM","0250","RC","69339-152-17","NDC",,,"facility","inpatient","16.600192","ML",,"1.94","1.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOMETHACIN 50 MG PR SUPP","81000000","CDM","0250","RC","69344-102-33","NDC",,,"facility","inpatient","1.288135","UN",,"1085.72","1085.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"K PHOS MONO-SOD PHOS DI & MONO 155-852-130 MG PO TABS","81000000","CDM","0250","RC","69367-250-01","NDC",,,"facility","inpatient","1.029438","UN",,"10.07","10.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN","81000000","CDM","0250","RC","69367-272-04","NDC",,,"facility","inpatient","118.003269","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERGOCALCIFEROL 200 MCG/ML PO SOLN","81000000","CDM","0250","RC","69367-283-02","NDC",,,"facility","inpatient","59.997839","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL CONTINUOUS NEB SIMPLE SH","81000000","CDM","0250","RC","69374-330-05","NDC",,,"facility","inpatient","5.000000","ML",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","81000000","CDM","0250","RC","69374-982-55","NDC",,,"facility","inpatient","5.886137","ML",,"83.82","83.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOFETILIDE 125 MCG PO CAPS","81000000","CDM","0250","RC","69452-131-17","NDC",,,"facility","inpatient","1.400000","UN",,"53.59","53.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOFETILIDE 250 MCG PO CAPS","81000000","CDM","0250","RC","69452-132-17","NDC",,,"facility","inpatient","1.496124","UN",,"50.87","50.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM CITRATE PO SOLN","81000000","CDM","0250","RC","69452-389-98","NDC",,,"facility","inpatient","333.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM CITRATE PO SOLN","81000000","CDM","0250","RC","69452-390-98","NDC",,,"facility","inpatient","296.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARISOPRODOL 350 MG PO TABS","81000000","CDM","0250","RC","69584-111-10","NDC",,,"facility","inpatient","1.258064","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SOTALOL HCL 160 MG PO TABS","81000000","CDM","0250","RC","69584-843-10","NDC",,,"facility","inpatient","1.000000","UN",,"21.53","21.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SOTALOL HCL 240 MG PO TABS","81000000","CDM","0250","RC","69584-844-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARTIFICIAL TEARS OP OINT - CONSOLIDATED","81000000","CDM","0250","RC","69618-060-76","NDC",,,"facility","inpatient","3.500000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM ACETATE 2 MEQ/ML IV SOLN","81000000","CDM","0250","RC","69784-230-10","NDC",,,"facility","inpatient","50.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM ACETATE 2 MEQ/ML IV SOLN","81000000","CDM","0250","RC","69784-230-20","NDC",,,"facility","inpatient","55.552191","ML",,"89.12","89.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 650 MG PO TABS","81000000","CDM","0250","RC","69918-301-30","NDC",,,"facility","inpatient","1.000000","UN",,"28.25","28.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT","81000000","CDM","0250","RC","69968-0060-9","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZINC OXIDE 40 % EX PSTE","81000000","CDM","0250","RC","69968-061-01","NDC",,,"facility","inpatient","28.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG/SPRAY TL SOLN","81000000","CDM","0250","RC","70007-300-65","NDC",,,"facility","inpatient","5.186131","GR",,"1189.46","1189.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TROPICAMIDE 1 % OP SOLN","81000000","CDM","0250","RC","70069-121-01","NDC",,,"facility","inpatient","16.834532","ML",,"164.73","164.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 0.3 % OP SOLN","81000000","CDM","0250","RC","70069-131-01","NDC",,,"facility","inpatient","12.058823","ML",,"40.63","40.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE (PF) 10 MG/5ML IV SOLN","81000000","CDM","0250","RC","70069-141-01","NDC",,,"facility","inpatient","5.000000","ML",,"105.25","105.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN","81000000","CDM","0250","RC","70069-141-10","NDC",,,"facility","inpatient","5.000000","ML",,"97.5","97.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN","81000000","CDM","0250","RC","70069-161-01","NDC",,,"facility","inpatient","12.631578","ML",,"179.4","179.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN","81000000","CDM","0250","RC","70069-161-10","NDC",,,"facility","inpatient","10.560224","ML",,"179.4","179.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PILOCARPINE HCL 1 % OP SOLN","81000000","CDM","0250","RC","70069-181-01","NDC",,,"facility","inpatient","15.000000","ML",,"375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PILOCARPINE HCL 2 % OP SOLN","81000000","CDM","0250","RC","70069-191-01","NDC",,,"facility","inpatient","15.000000","ML",,"379.38","379.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BRIMONIDINE TARTRATE 0.2 % OP SOLN","81000000","CDM","0250","RC","70069-231-01","NDC",,,"facility","inpatient","5.810810","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALGANCICLOVIR HCL 50 MG/ML PO SOLR","81000000","CDM","0250","RC","70069-810-01","NDC",,,"facility","inpatient","91.693784","ML",,"366.45","366.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL-BUPIVACAINE-NACL 0.5-0.125-0.9 MG/250ML-% EP SOLN","81000000","CDM","0250","RC","70092-1105-37","NDC",,,"facility","inpatient","250.000000","ML",,"233.93","233.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETAMINE 10MG/ML INJ (PEDIATRIC) SH","81000000","CDM","0250","RC","70092-1119-44","NDC",,,"facility","inpatient","5.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPHEDRINE SULFATE 5 MG/ML INJ (SH)","81000000","CDM","0250","RC","70092-1478-44","NDC",,,"facility","inpatient","5.704225","ML",,"115.85","115.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL-BUPIVACAINE-NACL 0.2-0.1-0.9 MG/100ML-% EP SOLN","81000000","CDM","0250","RC","70092-1499-36","NDC",,,"facility","inpatient","100.000000","ML",,"186.5","186.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE/EPINEPHRINE/TETRACAINE (L.E.T) TOP SOLN CUSTOM CREATE","81000000","CDM","0250","RC","70092-1658-44","NDC",,,"facility","inpatient","3.078462","ML",,"40.90","40.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPHEDRINE SULFATE 5 MG/ML INJ (SH)","81000000","CDM","0250","RC","70092-2478-44","NDC",,,"facility","inpatient","5.000000","ML",,"85.07","85.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDOCYANINE GREEN 25 MG IV SOLR","81000000","CDM","0250","RC","70100-424-01","NDC",,,"facility","inpatient","1.000000","UN",,"84.73","84.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 200 MCG/50ML IV SOLN","81000000","CDM","0250","RC","70121-1388-1","NDC",,,"facility","inpatient","450.000000","ML",,"349.05","349.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN","81000000","CDM","0250","RC","70121-1389-1","NDC",,,"facility","inpatient","115.384615","ML",,"639.6","639.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CANNABIDIOL 100 MG/ML PO SOLN","81000000","CDM","0250","RC","70127-100-06","NDC",,,"facility","inpatient","59.998781","ML",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL 2 % OP SOLN","81000000","CDM","0250","RC","70377-081-11","NDC",,,"facility","inpatient","10.000000","ML",,"334","334",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCUSATE SODIUM 100 MG PO CAPS","81000000","CDM","0250","RC","70677-0034-1","NDC",,,"facility","inpatient","1.000000","UN",,"1.96","1.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","70677-1037-1","NDC",,,"facility","inpatient","30.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYMETAZOLINE HCL 0.05 % NA SOLN","81000000","CDM","0250","RC","70677-1040-1","NDC",,,"facility","inpatient","30.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM CITRATE PO SOLN","81000000","CDM","0250","RC","70677-1111-1","NDC",,,"facility","inpatient","327.714285","ML",,"1.97","1.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBAMIDE PEROXIDE 6.5 % OT SOLN","81000000","CDM","0250","RC","70677-1154-1","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROGEN PEROXIDE 3 % EX SOLN","81000000","CDM","0250","RC","70677-1248-1","NDC",,,"facility","inpatient","473.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROGESTERONE 100 MG PO CAPS","81000000","CDM","0250","RC","70700-162-01","NDC",,,"facility","inpatient","1.301886","UN",,"25.19","25.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOSFOMYCIN TROMETHAMINE 3 G PO PACK","81000000","CDM","0250","RC","70700-268-94","NDC",,,"facility","inpatient","1.000000","UN",,"301.2","301.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOSFOMYCIN TROMETHAMINE 3 G PO PACK","81000000","CDM","0250","RC","70700-268-99","NDC",,,"facility","inpatient","1.000000","UN",,"301.2","301.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MECLIZINE HCL 12.5 MG PO TABS","81000000","CDM","0250","RC","70710-1161-1","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DROXIDOPA 100 MG PO CAPS","81000000","CDM","0250","RC","70710-1389-9","NDC",,,"facility","inpatient","1.000000","UN",,"100.76","100.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 200 MG/5ML PO SUSR","81000000","CDM","0250","RC","70710-1460-2","NDC",,,"facility","inpatient","29.999447","ML",,"36.81","36.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL 2.5 MG/ML IV SOLN","81000000","CDM","0250","RC","70710-1643-7","NDC",,,"facility","inpatient","2.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN","81000000","CDM","0250","RC","70710-1838-1","NDC",,,"facility","inpatient","10.000000","ML",,"1125.08","1125.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN","81000000","CDM","0250","RC","70710-1838-5","NDC",,,"facility","inpatient","10.000000","ML",,"385.73","385.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NETARSUDIL DIMESYLATE 0.02 % OP SOLN","81000000","CDM","0250","RC","70727-497-25","NDC",,,"facility","inpatient","2.500000","ML",,"50.61","50.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POSACONAZOLE 100 MG PO TBEC","81000000","CDM","0250","RC","70748-258-07","NDC",,,"facility","inpatient","1.122919","UN",,"222.02","222.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYPROHEPTADINE HCL 2 MG/5ML PO SYRP","81000000","CDM","0250","RC","70752-101-12","NDC",,,"facility","inpatient","633.973221","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CETIRIZINE HCL 1 MG/ML PO SOLN","81000000","CDM","0250","RC","70752-104-06","NDC",,,"facility","inpatient","128.269591","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX OINT","81000000","CDM","0250","RC","70752-113-03","NDC",,,"facility","inpatient","35.440000","GR",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 0.4 MG SL SUBL","81000000","CDM","0250","RC","70756-014-02","NDC",,,"facility","inpatient","30.555555","UN",,"128.38","128.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 10 MG PO TABS","81000000","CDM","0250","RC","70756-201-11","NDC",,,"facility","inpatient","1.043478","UN",,"14.48","14.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMITRIPTYLINE HCL 75 MG PO TABS","81000000","CDM","0250","RC","70756-204-11","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OFLOXACIN 0.3 % OP SOLN","81000000","CDM","0250","RC","70756-607-30","NDC",,,"facility","inpatient","7.666666","ML",,"351.75","351.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OFLOXACIN 0.3 % OT SOLN","81000000","CDM","0250","RC","70756-609-15","NDC",,,"facility","inpatient","5.000000","ML",,"629.36","629.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OFLOXACIN 0.3 % OT SOLN","81000000","CDM","0250","RC","70756-610-30","NDC",,,"facility","inpatient","10.000000","ML",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL 10 % OP SOLN","81000000","CDM","0250","RC","70756-614-30","NDC",,,"facility","inpatient","5.000000","ML",,"128.59","128.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL 2.5 % OP SOLN","81000000","CDM","0250","RC","70756-629-25","NDC",,,"facility","inpatient","2.402435","ML",,"190.34","190.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000000","CDM","0250","RC","70860-451-10","NDC",,,"facility","inpatient","1.000000","UN",,"454.89","454.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PRAZOSIN HCL 5 MG PO CAPS","81000000","CDM","0250","RC","70954-021-10","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIFABUTIN 150 MG PO CAPS","81000000","CDM","0250","RC","70954-041-10","NDC",,,"facility","inpatient","1.065040","UN",,"57.48","57.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPSONE 25 MG PO TABS","81000000","CDM","0250","RC","70954-135-20","NDC",,,"facility","inpatient","1.000000","UN",,"12.11","12.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPSONE 100 MG PO TABS","81000000","CDM","0250","RC","70954-136-10","NDC",,,"facility","inpatient","1.000000","UN",,"16.63","16.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DAPSONE 100 MG PO TABS","81000000","CDM","0250","RC","70954-136-20","NDC",,,"facility","inpatient","1.041343","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOCARNITINE 1 GM/10ML PO SOLN","81000000","CDM","0250","RC","70954-140-10","NDC",,,"facility","inpatient","117.994100","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAPROXEN 125 MG/5ML PO SUSP","81000000","CDM","0250","RC","70954-151-10","NDC",,,"facility","inpatient","500.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIHEXYPHENIDYL HCL 2 MG PO TABS","81000000","CDM","0250","RC","70954-212-10","NDC",,,"facility","inpatient","1.000000","UN",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 10 MG/5ML PO SOLN","81000000","CDM","0250","RC","70954-261-10","NDC",,,"facility","inpatient","473.036896","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUPHENAZINE HCL 1 MG PO TABS","81000000","CDM","0250","RC","70954-273-10","NDC",,,"facility","inpatient","1.000000","UN",,"24.16","24.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PAROXETINE HCL 10 MG/5ML PO SUSP","81000000","CDM","0250","RC","70954-319-10","NDC",,,"facility","inpatient","250.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRAZINAMIDE 500 MG PO TABS","81000000","CDM","0250","RC","70954-484-10","NDC",,,"facility","inpatient","1.000000","UN",,"24.53","24.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOCARNITINE 330 MG PO TABS","81000000","CDM","0250","RC","70954-492-10","NDC",,,"facility","inpatient","1.000000","UN",,"0.72","0.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 4 % EX SOLN","81000000","CDM","0250","RC","70954-518-10","NDC",,,"facility","inpatient","50.000000","ML",,"323.25","323.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN","81000000","CDM","0250","RC","71225-133-01","NDC",,,"facility","inpatient","123.529411","ML",,"468","468",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISATRACURIUM BESYLATE (PF) 200 MG/20ML IV SOLN","81000000","CDM","0250","RC","71288-713-21","NDC",,,"facility","inpatient","20.000000","ML",,"390","390",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM ACETATE (PHOS BINDER) 667 MG PO TABS","81000000","CDM","0250","RC","71321-803-20","NDC",,,"facility","inpatient","1.049351","UN",,"9.51","9.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG PO PACK","81000000","CDM","0250","RC","71351-010-99","NDC",,,"facility","inpatient","1.000000","UN",,"1.67","1.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACIDOPHILUS PO TABS","81000000","CDM","0250","RC","71351-012-50","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE 1 % EX LOTN","81000000","CDM","0250","RC","71399-0120-1","NDC",,,"facility","inpatient","120.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMINS A & D EX OINT","81000000","CDM","0250","RC","71399-0122-4","NDC",,,"facility","inpatient","113.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","71456-001-01","NDC",,,"facility","inpatient","10.476190","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMINOLEVULINIC ACID HCL 1.5 G PO SOLR","81000000","CDM","0250","RC","71469-231-01","NDC",,,"facility","inpatient","1.000000","UN",,"7362.96","7362.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN","81000000","CDM","0250","RC","71921-226-10","NDC",,,"facility","inpatient","10.000000","ML",,"490.4","490.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AQUAPHOR EX OINT","81000000","CDM","0250","RC","72140-45231","NDC",,,"facility","inpatient","54.371584","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AQUAPHOR EX OINT","81000000","CDM","0250","RC","72140-63608","NDC",,,"facility","inpatient","396.000000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROSUVASTATIN CALCIUM 20 MG PO TABS","81000000","CDM","0250","RC","72205-004-90","NDC",,,"facility","inpatient","1.118518","UN",,"40.66","40.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATORVASTATIN CALCIUM 80 MG PO TABS","81000000","CDM","0250","RC","72205-025-90","NDC",,,"facility","inpatient","1.136752","UN",,"31.76","31.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","81000000","CDM","0250","RC","72205-044-11","NDC",,,"facility","inpatient","1.200000","UN",,"61.83","61.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBENDAZOLE 200 MG PO TABS","81000000","CDM","0250","RC","72205-051-08","NDC",,,"facility","inpatient","1.000000","UN",,"686.72","686.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOMIDATE 2 MG/ML IV SOLN","81000000","CDM","0250","RC","72266-146-01","NDC",,,"facility","inpatient","10.000000","ML",,"64.66","64.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MOXIFLOXACIN HCL 0.5 % OP SOLN","81000000","CDM","0250","RC","72266-158-01","NDC",,,"facility","inpatient","3.545454","ML",,"69.39","69.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORZOLAMIDE HCL 2 % OP SOLN","81000000","CDM","0250","RC","72266-197-01","NDC",,,"facility","inpatient","10.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL 2.5 MG/ML IV SOLN","81000000","CDM","0250","RC","72485-108-05","NDC",,,"facility","inpatient","2.000000","ML",,"87.44","87.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN 5 MG/GM OP OINT","81000000","CDM","0250","RC","72485-670-31","NDC",,,"facility","inpatient","1.020512","GR",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","72603-209-01","NDC",,,"facility","inpatient","52.966625","ML",,"81.62","81.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","72603-209-25","NDC",,,"facility","inpatient","50.000000","ML",,"81.9","81.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 1 MG/5ML PO SOLN","81000000","CDM","0250","RC","72603-240-01","NDC",,,"facility","inpatient","473.036896","ML",,"31.35","31.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RIMEGEPANT SULFATE 75 MG PO TBDP","81000000","CDM","0250","RC","72618-3000-2","NDC",,,"facility","inpatient","1.000000","UN",,"449.56","449.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARVEDILOL 6.25 MG PO TABS","81000000","CDM","0250","RC","72888-035-01","NDC",,,"facility","inpatient","1.165975","UN",,"14.02","14.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 400 MG PO TABS","81000000","CDM","0250","RC","72888-061-30","NDC",,,"facility","inpatient","1.007707","UN",,"40.05","40.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 10440-39150 UNITS PO TABS","81000000","CDM","0250","RC","73562-104-10","NDC",,,"facility","inpatient","1.000000","UN",,"27.22","27.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 10000-32000 UNITS PO CPEP","81000000","CDM","0250","RC","73562-110-01","NDC",,,"facility","inpatient","1.000000","UN",,"24.51","24.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 15000-47000 UNITS PO CPEP","81000000","CDM","0250","RC","73562-111-01","NDC",,,"facility","inpatient","1.057971","UN",,"33.09","33.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 20000-63000 UNITS PO CPEP","81000000","CDM","0250","RC","73562-112-01","NDC",,,"facility","inpatient","1.166666","UN",,"41.14","41.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANCRELIPASE (LIP-PROT-AMYL) 5000-24000 UNITS PO CPEP","81000000","CDM","0250","RC","73562-115-01","NDC",,,"facility","inpatient","1.000000","UN",,"14.19","14.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZINC OXIDE 40 % EX PSTE","81000000","CDM","0250","RC","74300-00070","NDC",,,"facility","inpatient","58.605633","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENAZOPYRIDINE HCL 200 MG PO TABS","81000000","CDM","0250","RC","75826-115-10","NDC",,,"facility","inpatient","1.173913","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL ER 180 MG PO TBCR","81000000","CDM","0250","RC","75834-158-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VERAPAMIL HCL ER 240 MG PO TBCR","81000000","CDM","0250","RC","75834-159-01","NDC",,,"facility","inpatient","1.065573","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZINC OXIDE 20 % EX OINT","81000000","CDM","0250","RC","75834-170-01","NDC",,,"facility","inpatient","28.400000","GR",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN BASE 250 MG PO TABS","81000000","CDM","0250","RC","75834-242-30","NDC",,,"facility","inpatient","1.000000","UN",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML PO SOLN","81000000","CDM","0250","RC","75834-280-30","NDC",,,"facility","inpatient","5.208333","ML",,"1204.92","1204.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5ML PO SUSR","81000000","CDM","0250","RC","75834-294-01","NDC",,,"facility","inpatient","99.968010","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR","81000000","CDM","0250","RC","75834-295-01","NDC",,,"facility","inpatient","133.333333","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THYROID 120 MG PO TABS","81000000","CDM","0250","RC","75834-314-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN","81000000","CDM","0250","RC","76014-005-25","NDC",,,"facility","inpatient","1.036673","ML",,"86.73","86.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 3% IN NEBU","81000000","CDM","0250","RC","76204-022-60","NDC",,,"facility","inpatient","5.900990","ML",,"1.92","1.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMFIBROZIL 600 MG PO TABS","81000000","CDM","0250","RC","76282-225-60","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 400 MCG/SPRAY TL AERS","81000000","CDM","0250","RC","76299-430-04","NDC",,,"facility","inpatient","4.100000","GR",,"1200","1200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY","81000000","CDM","0250","RC","76329-3011-5","NDC",,,"facility","inpatient","5.000000","ML","PN","2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE 2% GEL UROJET INJ SH","81000000","CDM","0250","RC","76329-3013-5","NDC",,,"facility","inpatient","11.348314","ML",,"2.54","2.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CHLORIDE 10 % IV SOLN","81000000","CDM","0250","RC","76329-3304-1","NDC",,,"facility","inpatient","10.299376","ML",,"85.61","85.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE 0.1MG/ML INJ (PEDIATRIC) SH","81000000","CDM","0250","RC","76329-3318-1","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 8.4 % IV SOLN","81000000","CDM","0250","RC","76329-3352-1","NDC",,,"facility","inpatient","60.744023","ML",,"146.25","146.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 4 % MT SOLN","81000000","CDM","0250","RC","76329-6300-5","NDC",,,"facility","inpatient","4.621359","ML",,"93.09","93.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE-NACL 5-0.9 MG/250ML-% IV SOLN","81000000","CDM","0250","RC","76329-9061-0","NDC",,,"facility","inpatient","1620.503304","ML",,"975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIOGUANINE 40 MG PO TABS","81000000","CDM","0250","RC","76388-880-25","NDC",,,"facility","inpatient","3.400000","UN",,"3.36","3.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYOSCYAMINE SULFATE 0.125 MG SL SUBL","81000000","CDM","0250","RC","76439-309-10","NDC",,,"facility","inpatient","1.888888","UN",,"14.30","14.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLY-VI-SOL PO SOLN","81000000","CDM","0250","RC","76518-030-50","NDC",,,"facility","inpatient","47.591743","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 3 MG PO TABS","81000000","CDM","0250","RC","77333-516-25","NDC",,,"facility","inpatient","1.168674","UN",,"1.98","1.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 5 MG PO TABS","81000000","CDM","0250","RC","77333-520-25","NDC",,,"facility","inpatient","1.040383","UN",,"1.42","1.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SACCHAROMYCES BOULARDII 250 MG PO CAPS","81000000","CDM","0250","RC","77333-800-25","NDC",,,"facility","inpatient","1.000000","UN",,"1.82","1.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIMETHICONE 80 MG PO CHEW","81000000","CDM","0250","RC","77333-812-25","NDC",,,"facility","inpatient","1.079274","UN",,"1.73","1.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM BICARBONATE 650 MG PO TABS","81000000","CDM","0250","RC","77333-831-25","NDC",,,"facility","inpatient","1.000000","UN",,"1.75","1.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 1 G PO TABS","81000000","CDM","0250","RC","77333-835-25","NDC",,,"facility","inpatient","1.000000","UN",,"1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 1 G PO TABS","81000000","CDM","0250","RC","77333-844-10","NDC",,,"facility","inpatient","1.056338","UN",,"1.33","1.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL/MONONITRATE 100 MG PO TABS - CONSOLIDATED","81000000","CDM","0250","RC","77333-934-25","NDC",,,"facility","inpatient","1.096491","UN",,"1.97","1.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG PO TABS","81000000","CDM","0250","RC","77333-938-25","NDC",,,"facility","inpatient","1.110344","UN",,"1.95","1.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PYRIDOXINE HCL 50 MG PO TABS","81000000","CDM","0250","RC","77333-940-25","NDC",,,"facility","inpatient","1.020942","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHOLECALCIFEROL 10 MCG (400 UNIT) PO TABS","81000000","CDM","0250","RC","77333-948-25","NDC",,,"facility","inpatient","1.000000","UN",,"1.86","1.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN E 400 UNITS PO CAPS","81000000","CDM","0250","RC","77333-951-25","NDC",,,"facility","inpatient","1.031872","UN",,"1.97","1.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZINC SULFATE 220 (50 ZN) MG PO CAPS","81000000","CDM","0250","RC","77333-983-25","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE-MENTHOL 6-10 MG MT LOZG","81000000","CDM","0250","RC","78112-01106","NDC",,,"facility","inpatient","1.078014","UN",,"1.99","1.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE-MENTHOL 6-10 MG MT LOZG","81000000","CDM","0250","RC","78112-01107","NDC",,,"facility","inpatient","1.080000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE-MENTHOL 6-10 MG MT LOZG","81000000","CDM","0250","RC","78112-01266","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZOCAINE 15 MG MT LOZG","81000000","CDM","0250","RC","78112-10189","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBAMIDE PEROXIDE 6.5 % OT SOLN","81000000","CDM","0250","RC","78112-73621","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBAMIDE PEROXIDE 6.5 % OT SOLN","81000000","CDM","0250","RC","78112-73623","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM HYALURONATE 5.5 MG/0.55ML IO SOSY","81000000","CDM","0250","RC","8065-183055","NDC",,,"facility","inpatient","0.904146","ML",,"811.71","811.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NA CHONDROIT SULF-NA HYALURON 20-15 MG/0.5ML IO SOSY","81000000","CDM","0250","RC","8065-183905","NDC",,,"facility","inpatient","0.546747","ML",,"1049.94","1049.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NIACINAMIDE 500 MG PO TABS","81000000","CDM","0250","RC","80681-01900","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MELATONIN 1 MG PO TABS","81000000","CDM","0250","RC","80681-04100","NDC",,,"facility","inpatient","1.111111","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 100 MCG PO TABS","81000000","CDM","0250","RC","80681-07100","NDC",,,"facility","inpatient","1.000000","UN",,"1.70","1.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN B-1 50 MG PO TABS","81000000","CDM","0250","RC","80681-09700","NDC",,,"facility","inpatient","1.000000","UN",,"1","1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VITAMIN E 100 UNITS PO CAPS","81000000","CDM","0250","RC","80681-13400","NDC",,,"facility","inpatient","2.333333","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM CITRATE 950 (200 CA) MG PO TABS","81000000","CDM","0250","RC","80681-14000","NDC",,,"facility","inpatient","1.027531","UN",,"1.03","1.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIOGUANINE 40 MG PO TABS","81000000","CDM","0250","RC","80725-630-25","NDC",,,"facility","inpatient","5.000000","UN",,"476.40","476.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","80830-1691-1","NDC",,,"facility","inpatient","16.136316","ML",,"162.02","162.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN","81000000","CDM","0250","RC","80830-1691-2","NDC",,,"facility","inpatient","14.999947","ML",,"162","162",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN","81000000","CDM","0250","RC","81033-220-52","NDC",,,"facility","inpatient","15.000000","ML",,"1","1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INDIGOTINDISULFONATE SODIUM 8 MG/ML IV SOLN","81000000","CDM","0250","RC","81284-315-05","NDC",,,"facility","inpatient","7.857142","ML",,"2000","2000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000000","CDM","0250","RC","81284-611-00","NDC",,,"facility","inpatient","11.263157","ML",,"65.56","65.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000000","CDM","0250","RC","81284-611-10","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXIDIZED CELLULOSE 6X9 IN EX FAB KNITTED","81000000","CDM","0250","RC","8137-001946","NDC",,,"facility","inpatient","1.025356","EA",,"180.94","180.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXIDIZED CELLULOSE ADHESION BARRIER PADS","81000000","CDM","0250","RC","8137-004350","NDC",,,"facility","inpatient","1.296296","EA",,"329.48","329.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE 5 % EX PTCH","81000000","CDM","0250","RC","82347-0505-5","NDC",,,"facility","inpatient","1.155565","UN",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXEGOL OXALATE 12.5 MG PO TABS","81000000","CDM","0250","RC","82625-8801-1","NDC",,,"facility","inpatient","1.024844","UN",,"62.88","62.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXEGOL OXALATE 25 MG PO TABS","81000000","CDM","0250","RC","82625-8802-3","NDC",,,"facility","inpatient","1.176870","UN",,"66.19","66.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTINEX PO PACK","81000000","CDM","0250","RC","8290-236712","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IV SOLN CONSOLIDATED","81000000","CDM","0250","RC","8290-306499","NDC",,,"facility","inpatient","99.841269","ML",,"9.28","9.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IV SOLN CONSOLIDATED","81000000","CDM","0250","RC","8290-306544","NDC",,,"facility","inpatient","4.911520","ML",,"13.67","13.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IV SOLN CONSOLIDATED","81000000","CDM","0250","RC","8290-306546","NDC",,,"facility","inpatient","10.000000","ML","PN","14.42","14.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NACL 0.9% FLUSH IV SOLN CONSOLIDATED","81000000","CDM","0250","RC","8290-306546","NDC",,,"facility","inpatient","12.500000","ML",,"11.39","11.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IV SOLN CONSOLIDATED","81000000","CDM","0250","RC","8290-306547","NDC",,,"facility","inpatient","10.000000","ML","PN","11.91","11.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NACL 0.9% FLUSH IV SOLN CONSOLIDATED","81000000","CDM","0250","RC","8290-306547","NDC",,,"facility","inpatient","19.898989","ML",,"11.83","11.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM HYALURONATE 13.8 MG/0.6ML IO SOSY","81000000","CDM","0250","RC","8544-508321","NDC",,,"facility","inpatient","0.600000","ML",,"702.04","702.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM HYALURONATE 8.5 MG/0.85ML IO SOSY","81000000","CDM","0250","RC","8544-508421","NDC",,,"facility","inpatient","0.859214","ML",,"932.60","932.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM HYALURONATE 8.5 MG/0.85ML IO SOSY","81000000","CDM","0250","RC","8544-636981","NDC",,,"facility","inpatient","0.850000","ML","RISK","833.33","833.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"SODIUM HYALURONATE 8.5 MG/0.85ML IO SOSY","81000000","CDM","0250","RC","8544-636981","NDC",,,"facility","inpatient","0.886756","ML",,"950.35","950.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM HYALURONATE 13.8 MG/0.6ML IO SOSY","81000000","CDM","0250","RC","8544-636991","NDC",,,"facility","inpatient","0.600000","ML",,"744.34","744.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TETRAHYDROZOLINE HCL 0.05 % OP SOLN","81000000","CDM","0250","RC","87701-14975","NDC",,,"facility","inpatient","15.000000","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IV SOLN CONSOLIDATED","81000000","CDM","0250","RC","8881-570121","NDC",,,"facility","inpatient","15.116279","ML",,"5.56","5.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IJ SOLN RADIOLOGY SH","81000000","CDM","0250","RC","8881-579121","NDC",,,"facility","inpatient","13.636363","ML",,"1.95","1.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 250 MG/5ML (5%) PO SUSR","81000000","CDM","0250","RC","99999-0001-71","NDC",,,"facility","inpatient","1.000000","ML",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE 40 MG/ML PO SUSR","81000000","CDM","0250","RC","99999-0002-63","NDC",,,"facility","inpatient","1.000000","ML",,"17.12","17.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYCODONE HCL 100 MG/5ML PO CONC","81000000","CDM","0250","RC","99999-0004-05","NDC",,,"facility","inpatient","1.078222","ML",,"20.40","20.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POLY-VI-SOL/IRON 11 MG/ML PO SOLN","81000000","CDM","0250","RC","99999-0004-22","NDC",,,"facility","inpatient","1.004903","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PSYLLIUM VARIABLE DOSE POWDER SH","81000000","CDM","0250","RC","99999-0006-34","NDC",,,"facility","inpatient","1.000000","UN",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCROSE 24% SUCKING SOLN SH","81000000","CDM","0250","RC","99999-0006-37","NDC",,,"facility","inpatient","15.559626","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","99999-0007-46","NDC",,,"facility","inpatient","10.000000","ML",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","99999-0007-47","NDC",,,"facility","inpatient","32.046492","ML",,"26.00","26.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXIDIZED CELLULOSE 2X3 IN EX FAB SHEER","81000000","CDM","0250","RC","99999-0007-93","NDC",,,"facility","inpatient","1.000000","UN",,"92.44","92.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXIDIZED CELLULOSE 2X4 IN EX FAB FIBROUS","81000000","CDM","0250","RC","99999-0007-94","NDC",,,"facility","inpatient","1.054054","EA",,"237.28","237.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXIDIZED CELLULOSE 4X8 IN EX FAB SHEER","81000000","CDM","0250","RC","99999-0007-95","NDC",,,"facility","inpatient","1.068965","EA",,"126.63","126.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 5 MG/5ML PO SOLN","81000000","CDM","0250","RC","99999-0008-62","NDC",,,"facility","inpatient","10.000000","ML",,"13.15","13.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NAFCILLIN 40MG/ML IV SYRINGE (PEDIATRIC)","81000000","CDM","0250","RC","99999-0008-92","NDC",,,"facility","inpatient","1000.000000","ME",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"URSODIOL (ACTIGALL) 25 MG/ML ORAL SUSPENSION","81000000","CDM","0250","RC","99999-0010-24","NDC",,,"facility","inpatient","1.000000","ML",,"3.17","3.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OPIUM 10MG/ML (1%) PO TINC SH","81000000","CDM","0250","RC","99999-0010-70","NDC",,,"facility","inpatient","1.000000","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR","81000000","CDM","0250","RC","99999-0010-76","NDC",,,"facility","inpatient","5.000000","ML",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NXSTAGE PUREFLOW RFP 400 DIALYSATE SOLUTION","81000000","CDM","0250","RC","99999-0012-35","NDC",,,"facility","inpatient","5070.571630","ML",,"150.38","150.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NXSTAGE PUREFLOW RFP 402 DIALYSATE SOLUTION","81000000","CDM","0250","RC","99999-0012-36","NDC",,,"facility","inpatient","5000.000000","ML",,"150.21","150.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 10 MG/ML PO SOLN","81000000","CDM","0250","RC","99999-0013-85","NDC",,,"facility","inpatient","15.926696","ML",,"52.47","52.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SKIN ADHESIVE (DERMABOND, EXOFIN) EX LIQD SH","81000000","CDM","0250","RC","99999-0014-51","NDC",,,"facility","inpatient","0.500000","ML",,"82.52","82.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 10 MG/ML PO SOLN","81000000","CDM","0250","RC","99999-0015-12","NDC",,,"facility","inpatient","20.369515","ML",,"101.33","101.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SALT AND SODA MOUTHWASH (COMPOUND) SH","81000000","CDM","0250","RC","99999-0015-22","NDC",,,"facility","inpatient","10.311251","ML",,"13.24","13.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETHERIZED OXIDIZED CELLULOSE 0.5X2 IN EX PADS","81000000","CDM","0250","RC","99999-0015-33","NDC",,,"facility","inpatient","1.074074","UN",,"33.22","33.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SPIRONOLACTONE 5MG/ML ORAL SUSP (PEDIATRIC)","81000000","CDM","0250","RC","99999-0015-35","NDC",,,"facility","inpatient","1.000000","ML",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONAZEPAM 0.1MG/ML ORAL SUSP (PEDIATRIC) SH","81000000","CDM","0250","RC","99999-0015-40","NDC",,,"facility","inpatient","1.202898","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 1MEQ/ML ORAL SOLN (PEDIATRIC) SH","81000000","CDM","0250","RC","99999-0015-42","NDC",,,"facility","inpatient","1.000000","ML",,"1","1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 10 MG/5ML PO SOLN","81000000","CDM","0250","RC","99999-0015-73","NDC",,,"facility","inpatient","1.000000","ML",,"3","3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCERIN LIQD","81000000","CDM","0250","RC","99999-0015-75","NDC",,,"facility","inpatient","0.303697","ML",,"2","2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PAROXETINE HCL 10 MG/5ML PO SUSP","81000000","CDM","0250","RC","99999-0015-87","NDC",,,"facility","inpatient","10.000000","ML",,"32.97","32.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 50MG/ML ORAL SUSP *COMPOUNDED*","81000000","CDM","0250","RC","99999-0015-94","NDC",,,"facility","inpatient","10.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALLOPURINOL 20MG/ML ORAL LIQD *COMPOUNDED* (PEDIATRIC) SH","81000000","CDM","0250","RC","99999-0016-26","NDC",,,"facility","inpatient","1.000000","ML",,"1","1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZINC SULFATE 44MG/ML ORAL LIQUID *COMPOUND*","81000000","CDM","0250","RC","99999-0016-97","NDC",,,"facility","inpatient","50.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL 10MG/ML ORAL SUSP *COMPOUNDED* SH","81000000","CDM","0250","RC","99999-0017-89","NDC",,,"facility","inpatient","1.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NXSTAGE PUREFLOW RFP 404 DIALYSATE SOLUTION","81000000","CDM","0250","RC","99999-0019-21","NDC",,,"facility","inpatient","5067.577493","ML",,"157.38","157.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MINERAL OIL PO OIL","81000000","CDM","0250","RC","99999-0019-85","NDC",,,"facility","inpatient","30.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLONIDINE 10MCG/ML ORAL SUSP (NEONATAL) SH","81000000","CDM","0250","RC","99999-0020-53","NDC",,,"facility","inpatient","1.074340","ML",,"4.87","4.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NXSTAGE PUREFLOW RFP 401 DIALYSATE SOLUTION","81000000","CDM","0250","RC","99999-0020-54","NDC",,,"facility","inpatient","5251.091703","ML",,"150.47","150.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NXSTAGE PUREFLOW RFP 456 DIALYSATE SOLUTION","81000000","CDM","0250","RC","99999-0020-56","NDC",,,"facility","inpatient","5000.000000","ML",,"150.5","150.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 0.5 MG/ML ORAL LIQ *COMPOUND*","81000000","CDM","0250","RC","99999-0022-06","NDC",,,"facility","inpatient","2.059309","ML",,"37.80","37.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL 20 MG/5ML PO ELIX","81000000","CDM","0250","RC","99999-0023-34","NDC",,,"facility","inpatient","7.499959","ML",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFANT/TODDLER'S (UDO'S CHOICE) PROBIOTIC PO POWDER","81000000","CDM","0250","RC","99999-0023-36","NDC",,,"facility","inpatient","7.000000","GR",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ADENOSINE 100MCG/ML IN NS (CUSTOM) NARRATOR","81000000","CDM","0250","RC","99999-0023-69","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICARDIPINE 100MCG/ML IN NS (CUSTOM) NARRATOR","81000000","CDM","0250","RC","99999-0025-87","NDC",,,"facility","inpatient","16.666666","ML",,"677.56","677.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROPRUSSIDE 100MCG/ML IN D5W (CUSTOM) NARRATOR","81000000","CDM","0250","RC","99999-0025-88","NDC",,,"facility","inpatient","1","EA",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 10000.000000 MCG"
"ZINC SULFATE 44MG/ML ORAL LIQUID *COMPOUND*","81000000","CDM","0250","RC","99999-0030-45","NDC",,,"facility","inpatient","5.000000","ML",,"29.91","29.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOPROLOL 10MG/ML ORAL SUSP *COMPOUNDED* SH","81000000","CDM","0250","RC","99999-0030-65","NDC",,,"facility","inpatient","2.500000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROTHIAZIDE 50MG/ML PO SOLN SH","81000000","CDM","0250","RC","99999-0032-90","NDC",,,"facility","inpatient","1.000000","ML",,"120","120",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALUMINUM 1% IN SW IRRIGATION SH","81000000","CDM","0250","RC","99999-0036-50","NDC",,,"facility","inpatient","3000.000000","ML",,"1230","1230",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXIDIZED CELLULOSE 2X14 IN EX FAB SHEER","81000000","CDM","0250","RC","99999-0037-24","NDC",,,"facility","inpatient","1.108695","EA",,"253.26","253.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 50MG/ML ORAL SUSP *COMPOUNDED*","81000000","CDM","0250","RC","99999-0037-80","NDC",,,"facility","inpatient","10.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPOETIN ALFA 2,000 UNIT/ML INJ SOLN (NEONATAL)","81000005","CDM","0250","RC","J0885","HCPCS","59676-302-01","NDC","facility","inpatient","0.228684","ML","JZ","106.06","106.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA 2,000 UNIT/ML INJ SOLN (NEONATAL)","81000005","CDM","0250","RC","J0885","HCPCS","59676-302-01","NDC","facility","inpatient","2.235000","ML",,"124.62","124.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPOETIN ALFA 3000 UNIT/ML IJ SOLN (ESRD)","81000005","CDM","0250","RC","Q4081","HCPCS","59676-303-01","NDC","facility","inpatient","0.033333","ML","JZ","16.25","16.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000005","CDM","0250","RC","Q5105","HCPCS","0069-1308-10","NDC","facility","inpatient","0.010000","ML","JZ","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN (ESRD)","81000005","CDM","0250","RC","Q5105","HCPCS","0069-1307-10","NDC","facility","inpatient","0.025000","ML","JZ","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN (ESRD)","81000005","CDM","0250","RC","Q5105","HCPCS","0069-1305-10","NDC","facility","inpatient","0.050000","ML","JZ","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN (ESRD)","81000005","CDM","0250","RC","Q5105","HCPCS","0069-1306-10","NDC","facility","inpatient","0.034409","ML","JZ","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN (ESRD)","81000005","CDM","0634","RC","Q5105","HCPCS","0069-1307-10","NDC","facility","outpatient","0.025000","ML","JZ,JA","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously"
"EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN (ESRD)","81000005","CDM","0634","RC","Q5105","HCPCS","0069-1306-10","NDC","facility","outpatient","0.033333","ML","JZ,JA","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously"
"EPOETIN ALFA-EPBX 20,000 UNIT/ML IJ SOLN (ESRD)","81000006","CDM","0250","RC","Q5105","HCPCS","0069-1311-10","NDC","facility","inpatient","0.005540","ML",,"6.59","6.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN (ESRD)","81000006","CDM","0250","RC","Q5105","HCPCS","0069-1309-04","NDC","facility","inpatient","0.002500","ML","JZ","6.25","6.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000006","CDM","0250","RC","Q5105","HCPCS","0069-1308-10","NDC","facility","inpatient","0.010255","ML","JZ","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000006","CDM","0250","RC","Q5106","HCPCS","0069-1308-10","NDC","facility","inpatient","0.104436","ML","JZ","85.90","85.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000006","CDM","0635","RC","Q5105","HCPCS","0069-1308-10","NDC","facility","outpatient","0.010000","ML","JZ,JA","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously"
"EPOETIN ALFA-EPBX 20,000 UNIT/ML IJ SOLN (ESRD)","81000006","CDM","0635","RC","Q5105","HCPCS","0069-1311-10","NDC","facility","outpatient","0.005000","ML","JA","6.62","6.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000006","CDM","0635","RC","Q5105","HCPCS","0069-1308-10","NDC","facility","outpatient","0.010000","ML","JZ","8.60","8.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000006","CDM","0635","RC","Q5106","HCPCS","0069-1308-10","NDC","facility","outpatient","0.150000","ML","JZ","86.03","86.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPATITIS B VAC RECOMBINANT 5 MCG/0.5ML IJ SUSP","81000007","CDM","0250","RC","90744","HCPCS","0006-4981-00","NDC","facility","inpatient","0.500000","ML","JZ","210.53","210.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPATITIS B VAC RECOMBINANT 5 MCG/0.5ML IJ SUSY","81000007","CDM","0250","RC","90744","HCPCS","0006-4093-02","NDC","facility","inpatient","0.558891","ML","JZ","210.62","210.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR","81000007","CDM","0250","RC","J7187","HCPCS","63833-616-02","NDC","facility","inpatient","0.002000","UN","JZ","5.58","5.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR","81000007","CDM","0250","RC","J7189","HCPCS","0169-7201-01","NDC","facility","inpatient","1","EA","JZ","7.77","7.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 1.000000 MCG | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"COAGULATION FACTOR VIIA RECOMB 2000 MCG IV SOLR","81000007","CDM","0250","RC","J7189","HCPCS","0169-7202-01","NDC","facility","inpatient","0.000500","UN","JZ","7.77","7.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPATITIS B VAC RECOMBINANT 5 MCG/0.5ML IJ SUSY","81000007","CDM","0636","RC","90744","HCPCS","0006-4093-02","NDC","facility","outpatient","0.541493","ML","JZ","210.59","210.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"COAGULATION FACTOR VIIA RECOMB 2000 MCG IV SOLR","81000007","CDM","0636","RC","J7189","HCPCS","0169-7202-01","NDC","facility","outpatient","0.000500","UN","JZ","7.77","7.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR","81000007","CDM","0636","RC","J7189","HCPCS","0169-7201-01","NDC","facility","outpatient","0.001000","UN","JZ","7.77","7.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5ML IM SOSY","81000008","CDM","0250","RC","90371","HCPCS","13533-636-03","NDC","facility","inpatient","0.544444","ML","JZ","318.42","318.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NIRSEVIMAB-ALIP 50 MG/0.5ML IM SOSY","81000008","CDM","0250","RC","90380","HCPCS","49281-575-00","NDC","facility","inpatient","0.616666","ML","JZ","2500","2500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY","81000008","CDM","0250","RC","90384","HCPCS","0562-7805-01","NDC","facility","inpatient","1.307692","UN",,"819.91","819.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR","81000008","CDM","0250","RC","90399","HCPCS","58468-0080-1","NDC","facility","inpatient","1.573991","UN","JZ","3013.76","3013.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY","81000008","CDM","0250","RC","90620","HCPCS","58160-976-06","NDC","facility","inpatient","0.500000","ML",,"1320.43","1320.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR","81000008","CDM","0250","RC","90648","HCPCS","49281-545-03","NDC","facility","inpatient","1.444444","UN","JZ","107.23","107.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLUENZA VAC A&B SURF ANT ADJ 0.5 ML IM SUSY","81000008","CDM","0250","RC","90653","HCPCS","70461-024-04","NDC","facility","inpatient","1.045454","ML",,"571.25","571.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY","81000008","CDM","0250","RC","90653","HCPCS","70461-123-03","NDC","facility","inpatient","0.565573","ML",,"529.3","529.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY","81000008","CDM","0250","RC","90653","HCPCS","70461-123-04","NDC","facility","inpatient","1.000000","ML",,"529.3","529.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY","81000008","CDM","0250","RC","90654","HCPCS","70461-123-03","NDC","facility","inpatient","0.500000","ML",,"529.3","529.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VIRUS VACC SPLIT PF 0.5 ML IM SUSY","81000008","CDM","0250","RC","90656","HCPCS","19515-810-41","NDC","facility","inpatient","0.595238","ML",,"164.68","164.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PNEUMOCOCCAL 15-VAL CONJ VACC 0.5 ML IM SUSY","81000008","CDM","0250","RC","90671","HCPCS","0006-4329-03","NDC","facility","inpatient","0.500000","ML",,"1334.53","1334.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY","81000008","CDM","0250","RC","90677","HCPCS","0005-2000-02","NDC","facility","inpatient","0.554054","ML",,"1613.32","1613.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RSV PRE-FUSION F A&B VAC RCMB 120 MCG/0.5ML IM SOLR","81000008","CDM","0250","RC","90678","HCPCS","0069-0344-01","NDC","facility","inpatient","5.000000","UN",,"1770","1770",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY","81000008","CDM","0250","RC","90686","HCPCS","19515-814-41","NDC","facility","inpatient","0.500000","ML",,"164.68","164.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY","81000008","CDM","0250","RC","90686","HCPCS","19515-814-52","NDC","facility","inpatient","0.640000","ML",,"164.68","164.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DTAP-IPV-HIB VACCINE IM SUSR","81000008","CDM","0250","RC","90698","HCPCS","49281-511-05","NDC","facility","inpatient","1.076923","UN",,"887.15","887.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEASLES, MUMPS & RUBELLA VAC IJ SOLR","81000008","CDM","0250","RC","90707","HCPCS","0006-4681-00","NDC","facility","inpatient","1.048543","UN","JZ","718.97","718.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEASLES, MUMPS & RUBELLA VAC IJ SOLR","81000008","CDM","0250","RC","90707","HCPCS","0006-4681-00","NDC","facility","inpatient","0.500000","ML",,"718.53","718.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEASLES, MUMPS & RUBELLA VAC IJ SOLR","81000008","CDM","0250","RC","90707","HCPCS","50090-1860-0","NDC","facility","inpatient","0.500000","ML",,"640.57","640.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP","81000008","CDM","0250","RC","90715","HCPCS","49281-400-58","NDC","facility","inpatient","0.679104","ML","JZ","368.58","368.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP","81000008","CDM","0250","RC","90715","HCPCS","49281-400-20","NDC","facility","inpatient","0.500000","ML",,"367.88","367.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP","81000008","CDM","0250","RC","90715","HCPCS","49281-400-10","NDC","facility","inpatient","0.500000","ML","JZ","356.47","356.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ","81000008","CDM","0250","RC","90732","HCPCS","0006-4837-03","NDC","facility","inpatient","0.500000","ML","JZ","913.25","913.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ","81000008","CDM","0250","RC","90732","HCPCS","0006-4943-00","NDC","facility","inpatient","0.500000","ML","JZ","913.25","913.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MENINGOCOCCAL A C Y&W-135 OLIG IM SOLR","81000008","CDM","0250","RC","90734","HCPCS","58160-955-09","NDC","facility","inpatient","1.000000","UN",,"975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MENING ACY&W-135 TETANUS CONJ IM SOLN","81000008","CDM","0250","RC","90734","HCPCS","49281-590-58","NDC","facility","inpatient","0.875000","ML",,"997.41","997.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY","81000008","CDM","0250","RC","91322","HCPCS","80777-102-01","NDC","facility","inpatient","0.833333","ML",,"975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY","81000008","CDM","0250","RC","91322","HCPCS","80777-110-01","NDC","facility","inpatient","1.500000","ML",,"975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GADOXETATE DISODIUM 0.25 MMOL/ML IV SOLN","81000008","CDM","0250","RC","A9581","HCPCS","50419-320-01","NDC","facility","inpatient","0.975862","ML","JZ","44.76","44.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"COCAINE HCL 4 % EX SOLN","81000008","CDM","0250","RC","C9046","HCPCS","64950-362-04","NDC","facility","inpatient","0.025000","ML",,"5.51","5.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COCAINE HCL 4 % EX SOLN","81000008","CDM","0250","RC","C9046","HCPCS","0527-1728-74","NDC","facility","inpatient","0.025000","ML",,"4.18","4.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","C9113","HCPCS","0143-9284-10","NDC","facility","inpatient","1.050088","UN",,"74.58","74.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","C9113","HCPCS","25021-751-10","NDC","facility","inpatient","1.390720","UN",,"74.29","74.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","C9113","HCPCS","55150-202-10","NDC","facility","inpatient","1.349988","UN",,"74.50","74.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","C9113","HCPCS","0008-0923-55","NDC","facility","inpatient","1.253407","UN",,"74.22","74.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARGATROBAN 50 MG/50ML IV SOLN","81000008","CDM","0250","RC","C9121","HCPCS","0143-9559-01","NDC","facility","inpatient","6.250000","ML","JZ","118.8","118.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ARGATROBAN 50 MG/50ML IV SOLN","81000008","CDM","0250","RC","C9121","HCPCS","42367-203-84","NDC","facility","inpatient","5.000000","ML","JZ","136.2","136.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLEVIDIPINE 50 MG/100ML IV EMUL","81000008","CDM","0250","RC","C9248","HCPCS","10122-611-10","NDC","facility","inpatient","2.349286","ML","JZ","20.43","20.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LACOSAMIDE 200 MG/20ML IV SOLN","81000008","CDM","0250","RC","C9254","HCPCS","0131-1810-67","NDC","facility","inpatient","0.100000","ML",,"2.32","2.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 200 MG/20ML IV SOLN","81000008","CDM","0250","RC","C9254","HCPCS","25021-791-20","NDC","facility","inpatient","0.100000","ML",,"1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 200 MG/20ML IV SOLN","81000008","CDM","0250","RC","C9254","HCPCS","70710-1359-1","NDC","facility","inpatient","0.107229","ML",,"1.72","1.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BEVACIZUMAB 25 MG/ML INTRAVITREAL SOLN SH","81000008","CDM","0250","RC","C9257","HCPCS","70360-001-02","NDC","facility","inpatient","0.010000","ML","JZ","60","60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE LIPOSOME 1.3 % IJ SUSP","81000008","CDM","0250","RC","C9290","HCPCS","65250-266-09","NDC","facility","inpatient","0.074626","ML",,"10.95","10.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERLIPRESSIN ACETATE 0.85 MG IV SOLR","81000008","CDM","0250","RC","C9399","HCPCS","43825-200-01","NDC","facility","inpatient","1.756756","UN",,"4560","4560",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CANGRELOR TETRASODIUM 50 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","C9460","HCPCS","10122-620-10","NDC","facility","inpatient","0.021481","UN","JZ","91.63","91.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERAVACYCLINE DIHYDROCHLORIDE 50 MG IV SOLR","81000008","CDM","0250","RC","J0122","HCPCS","71773-050-12","NDC","facility","inpatient","0.020000","UN","JZ","9.42","9.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERAVACYCLINE DIHYDROCHLORIDE 100 MG IV SOLR","81000008","CDM","0250","RC","J0122","HCPCS","71773-100-05","NDC","facility","inpatient","0.010244","UN","JZ","8.57","8.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERAVACYCLINE DIHYDROCHLORIDE 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J0122","HCPCS","71773-100-12","NDC","facility","inpatient","0.010000","UN","JZ","7.98","7.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERAVACYCLINE DIHYDROCHLORIDE 100 MG IV SOLR","81000008","CDM","0250","RC","J0122","HCPCS","71773-100-05","NDC","facility","inpatient","0.010000","EA",,"7.26","7.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERAVACYCLINE DIHYDROCHLORIDE 50 MG IV SOLR","81000008","CDM","0250","RC","J0122","HCPCS","71773-050-12","NDC","facility","inpatient","1.000000","ME",,"9.59","9.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0131","HCPCS","24201-100-24","NDC","facility","inpatient","1.000000","ML","JZ,RISK","1.15","1.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0131","HCPCS","0781-3156-95","NDC","facility","inpatient","39.625000","ML",,"2.90","2.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0131","HCPCS","43825-102-01","NDC","facility","inpatient","5.325000","ML",,"3.69","3.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0131","HCPCS","55150-307-01","NDC","facility","inpatient","13.187500","ML",,"1.68","1.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0131","HCPCS","0781-3156-95","NDC","facility","inpatient","1.000000","ML","JZ","2.90","2.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0131","HCPCS","24201-100-24","NDC","facility","inpatient","1.069305","ML","JZ","0.94","0.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0131","HCPCS","43825-102-01","NDC","facility","inpatient","0.998211","ML","JZ","4.01","4.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0131","HCPCS","55150-307-24","NDC","facility","inpatient","1.103491","ML","JZ","1.68","1.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0250","RC","J0132","HCPCS","25021-812-30","NDC","facility","inpatient","0.612508","ML","JZ","14.65","14.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0250","RC","J0132","HCPCS","70594-111-01","NDC","facility","inpatient","0.495710","ML","JZ","7.73","7.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0250","RC","J0132","HCPCS","70594-111-02","NDC","facility","inpatient","0.499884","ML","JZ","7.39","7.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0250","RC","J0132","HCPCS","72611-860-01","NDC","facility","inpatient","0.496884","ML","JZ","4.78","4.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0250","RC","J0132","HCPCS","72611-860-04","NDC","facility","inpatient","0.497407","ML","JZ","4.80","4.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0250","RC","J0132","HCPCS","0574-0805-30","NDC","facility","inpatient","0.499334","ML",,"16.97","16.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR SODIUM 50 MG/ML IV SOLN","81000008","CDM","0250","RC","J0133","HCPCS","55150-155-20","NDC","facility","inpatient","0.119273","ML","JZ","1.05","1.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACYCLOVIR SODIUM 50 MG/ML IV SOLN","81000008","CDM","0250","RC","J0133","HCPCS","63323-325-03","NDC","facility","inpatient","0.106520","ML","JZ","1.86","1.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACYCLOVIR SODIUM 50 MG/ML IV SOLN","81000008","CDM","0250","RC","J0133","HCPCS","63323-325-10","NDC","facility","inpatient","0.099968","ML","JZ","2.20","2.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACYCLOVIR SODIUM 50 MG/ML IV SOLN","81000008","CDM","0250","RC","J0133","HCPCS","63323-325-20","NDC","facility","inpatient","0.106094","ML","JZ","1.45","1.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J0137","HCPCS","24201-100-24","NDC","facility","inpatient","1.006891","ML","JZ","0.97","0.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN","81000008","CDM","0250","RC","J0153","HCPCS","0409-1932-01","NDC","facility","inpatient","0.133300","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADENOSINE 6 MG/2ML IV SOLN","81000008","CDM","0250","RC","J0153","HCPCS","17478-542-02","NDC","facility","inpatient","0.688888","ML","JZ","11.32","11.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN","81000008","CDM","0250","RC","J0153","HCPCS","63323-651-30","NDC","facility","inpatient","0.333333","ML","JZ","12.94","12.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADENOSINE 6 MG/2ML IV SOLN","81000008","CDM","0250","RC","J0153","HCPCS","67457-855-02","NDC","facility","inpatient","0.470085","ML","JZ","11.06","11.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE 10MCG/ML INJ SOLN","81000008","CDM","0250","RC","J0171","HCPCS","0409-7241-01","NDC","facility","inpatient","3.333333","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0171","HCPCS","42023-159-25","NDC","facility","inpatient","0.100407","ML",,"18.33","18.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE (ANAPHYLAXIS) 30 MG/30ML IJ SOLN","81000008","CDM","0250","RC","J0171","HCPCS","42023-168-01","NDC","facility","inpatient","0.113036","ML",,"6.52","6.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE PF 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0171","HCPCS","54288-103-10","NDC","facility","inpatient","0.100000","ML",,"11.38","11.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE-NACL 5-0.9 MG/250ML-% IV SOLN","81000008","CDM","0250","RC","J0171","HCPCS","76329-9061-0","NDC","facility","inpatient","0.100000","ML",,"1.62","1.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0171","HCPCS","42023-159-25","NDC","facility","inpatient","0.100000","ML","RISK","12.57","12.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"EPINEPHRINE 1 MG/10ML IJ SOSY","81000008","CDM","0250","RC","J0171","HCPCS","76329-3316-1","NDC","facility","inpatient","1.000000","ML","JZ","25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE 0.1MG/ML INJ (PEDIATRIC) SH","81000008","CDM","0250","RC","J0171","HCPCS","76329-3318-1","NDC","facility","inpatient","1.427160","ML","JZ","11.73","11.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE HCL 0.1 MG/ML IJ SOLN (IO)","81000008","CDM","0250","RC","J0171","HCPCS","0409-4921-34","NDC","facility","inpatient","1.262463","ML","JZ","7.26","7.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE 1 MG/10ML IJ SOSY","81000008","CDM","0250","RC","J0171","HCPCS","0409-4933-11","NDC","facility","inpatient","1.000000","ML","JZ","10.89","10.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0171","HCPCS","42023-159-25","NDC","facility","inpatient","0.100000","ML","JZ","25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE PF 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0171","HCPCS","54288-103-10","NDC","facility","inpatient","0.125157","ML","JZ","17.58","17.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SODIUM THIOSULFATE 250 MG/ML IV SOLN","81000008","CDM","0250","RC","J0209","HCPCS","60267-705-50","NDC","facility","inpatient","0.400000","ML","JZ","6.03","6.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"REMDESIVIR 100 MG IV SOLR","81000008","CDM","0250","RC","J0248","HCPCS","61958-2901-1","NDC","facility","inpatient","0.016666","UN","JZ","24.97","24.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"REMDESIVIR 100 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J0248","HCPCS","61958-2901-2","NDC","facility","inpatient","0.010191","UN","JZ","28.78","28.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIKACIN SULFATE 500 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0278","HCPCS","0703-9032-03","NDC","facility","inpatient","0.400000","ML","JZ","20.59","20.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIKACIN SULFATE 500 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0278","HCPCS","0703-9040-03","NDC","facility","inpatient","0.400000","ML","JZ","19.74","19.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIKACIN SULFATE 500 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0278","HCPCS","23155-290-42","NDC","facility","inpatient","0.394520","ML","JZ","19.85","19.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIKACIN SULFATE 500 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0278","HCPCS","25021-173-04","NDC","facility","inpatient","0.400000","ML","JZ","12.78","12.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMINOPHYLLINE 25 MG/ML IV SOLN","81000008","CDM","0250","RC","J0280","HCPCS","0409-5922-16","NDC","facility","inpatient","1.562108","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMINOPHYLLINE 25 MG/ML IV SOLN","81000008","CDM","0250","RC","J0280","HCPCS","0409-5921-01","NDC","facility","inpatient","0.183714","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE HCL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J0282","HCPCS","67457-153-09","NDC","facility","inpatient","0.600000","ML","JZ","4.33","4.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE HCL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J0282","HCPCS","67457-153-03","NDC","facility","inpatient","0.600000","ML",,"10.91","10.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J0282","HCPCS","67457-153-09","NDC","facility","inpatient","0.600000","ML",,"4.33","4.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J0282","HCPCS","67457-153-03","NDC","facility","inpatient","0.594594","ML","JZ","16.19","16.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE HCL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J0282","HCPCS","67457-153-00","NDC","facility","inpatient","0.600000","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE HCL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J0282","HCPCS","63323-616-03","NDC","facility","inpatient","0.600000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J0282","HCPCS","43066-360-20","NDC","facility","inpatient","16.666666","ML","JZ","30.01","30.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE HCL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J0282","HCPCS","0143-9875-10","NDC","facility","inpatient","0.600000","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE LOAD DOSE 150MG/100ML(D5W) SH","81000008","CDM","0250","RC","J0282","HCPCS","43066-150-10","NDC","facility","inpatient","20.000000","ML","JZ","54.08","54.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE LOAD DOSE 150MG/100ML(D5W) SH","81000008","CDM","0250","RC","J0283","HCPCS","43066-150-10","NDC","facility","inpatient","22.308802","ML","JZ","53.88","53.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J0283","HCPCS","43066-360-20","NDC","facility","inpatient","17.648472","ML","JZ","30.01","30.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPHOTERICIN B 50 MG IV SOLR","81000008","CDM","0250","RC","J0285","HCPCS","39822-1055-5","NDC","facility","inpatient","1.000000","UN",,"390","390",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J0289","HCPCS","0469-3051-30","NDC","facility","inpatient","0.200000","UN","JZ","228.40","228.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J0289","HCPCS","55150-365-01","NDC","facility","inpatient","0.273420","UN","JZ","187.18","187.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J0289","HCPCS","62756-233-01","NDC","facility","inpatient","0.200000","UN","JZ","213.31","213.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J0289","HCPCS","0469-3051-30","NDC","facility","inpatient","0.220426","UN",,"247.88","247.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J0289","HCPCS","55150-365-01","NDC","facility","inpatient","0.200000","UN",,"240.71","240.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J0289","HCPCS","62756-233-01","NDC","facility","inpatient","0.200000","UN",,"241.82","241.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0290","HCPCS","0781-3404-95","NDC","facility","inpatient","0.277500","UN","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0290","HCPCS","55150-113-10","NDC","facility","inpatient","0.465000","UN","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","72485-422-01","NDC","facility","inpatient","0.458333","UN",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 250 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0250","RC","J0290","HCPCS","66794-220-02","NDC","facility","inpatient","0.861818","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 250 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0250","RC","J0290","HCPCS","0781-3402-95","NDC","facility","inpatient","0.739694","UN",,"74.90","74.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0290","HCPCS","0781-3404-95","NDC","facility","inpatient","0.544628","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 500 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0250","RC","J0290","HCPCS","0781-3407-95","NDC","facility","inpatient","0.890688","UN",,"74.26","74.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","0781-3408-95","NDC","facility","inpatient","0.265916","UN",,"29.32","29.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 250 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0250","RC","J0290","HCPCS","0781-9402-95","NDC","facility","inpatient","0.850000","UN",,"72.32","72.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","0781-3408-95","NDC","facility","inpatient","0.500000","GM","JZ","29.32","29.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN 1,000MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","0781-9404-85","NDC","facility","inpatient","25.467289","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","0781-9408-95","NDC","facility","inpatient","0.250000","UN",,"29.32","29.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","44567-103-10","NDC","facility","inpatient","0.250000","UN",,"23.1","23.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","55150-114-20","NDC","facility","inpatient","0.285294","UN",,"27.85","27.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","63323-399-23","NDC","facility","inpatient","26.819836","ML",,"18.77","18.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 250 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0250","RC","J0290","HCPCS","65219-014-01","NDC","facility","inpatient","1.063424","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 500 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0250","RC","J0290","HCPCS","65219-016-01","NDC","facility","inpatient","1.311000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0290","HCPCS","65219-020-03","NDC","facility","inpatient","0.274390","UN",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 500 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0250","RC","J0290","HCPCS","0781-9407-95","NDC","facility","inpatient","1.196891","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J0295","HCPCS","0641-6117-10","NDC","facility","inpatient","0.301339","UN","JZ","53.57","53.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR","81000008","CDM","0250","RC","J0295","HCPCS","55150-116-20","NDC","facility","inpatient","0.825000","UN","JZ","44.67","44.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J0295","HCPCS","55150-117-20","NDC","facility","inpatient","0.264375","UN","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR","81000008","CDM","0250","RC","J0295","HCPCS","0049-0013-83","NDC","facility","inpatient","0.810000","UN",,"55.92","55.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0295","HCPCS","0049-0014-83","NDC","facility","inpatient","0.500000","UN",,"61.14","61.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 1.5GM/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0295","HCPCS","0641-6116-10","NDC","facility","inpatient","1.000000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J0295","HCPCS","0641-6117-10","NDC","facility","inpatient","0.506980","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0295","HCPCS","25021-143-30","NDC","facility","inpatient","0.500000","UN",,"36.86","36.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0295","HCPCS","67457-349-03","NDC","facility","inpatient","0.500000","UN",,"53.80","53.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J0295","HCPCS","55150-117-20","NDC","facility","inpatient","0.526022","UN",,"51.1","51.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0295","HCPCS","71288-006-31","NDC","facility","inpatient","0.500000","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J0295","HCPCS","71288-032-20","NDC","facility","inpatient","0.617647","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J0295","HCPCS","72485-417-01","NDC","facility","inpatient","0.508097","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0295","HCPCS","99999-0011-13","NDC","facility","inpatient","50.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0330","HCPCS","0409-6629-02","NDC","facility","inpatient","1.081005","ML",,"16.05","16.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0330","HCPCS","0781-3411-95","NDC","facility","inpatient","0.611764","ML",,"16.79","16.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0330","HCPCS","71288-719-10","NDC","facility","inpatient","0.455000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0360","HCPCS","0641-6231-25","NDC","facility","inpatient","0.572580","ML",,"92","92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0360","HCPCS","55150-400-01","NDC","facility","inpatient","0.454545","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0360","HCPCS","63323-614-01","NDC","facility","inpatient","0.540699","ML",,"80.88","80.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0360","HCPCS","63323-614-55","NDC","facility","inpatient","0.416666","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 500 MG IV SOLR","81000008","CDM","0250","RC","J0456","HCPCS","63323-398-10","NDC","facility","inpatient","500.000000","ME",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 500 MG/250ML NS (VIAL-MATE)","81000008","CDM","0250","RC","J0456","HCPCS","70860-100-10","NDC","facility","inpatient","1.040178","UN",,"74.80","74.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 500 MG/250ML NS (VIAL-MATE)","81000008","CDM","0250","RC","J0456","HCPCS","99999-0011-14","NDC","facility","inpatient","288.643067","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 500 MG/250ML NS (VIAL-MATE)","81000008","CDM","0250","RC","J0456","HCPCS","55150-174-10","NDC","facility","inpatient","1.163934","UN",,"77","77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZTREONAM 1 G IJ SOLR","81000008","CDM","0250","RC","J0457","HCPCS","63323-401-01","NDC","facility","inpatient","0.100000","UN","JZ","28.86","28.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZTREONAM 2000 MG/8ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J0457","HCPCS","63323-402-20","NDC","facility","inpatient","0.050000","UN","JZ","28.59","28.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZTREONAM 1000 MG/4ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J0457","HCPCS","0409-0829-11","NDC","facility","inpatient","0.100000","UN",,"25.74","25.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZTREONAM 1 G IJ SOLR","81000008","CDM","0250","RC","J0457","HCPCS","63323-401-01","NDC","facility","inpatient","0.100000","UN",,"28.14","28.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZTREONAM 2000 MG/8ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J0457","HCPCS","63323-402-20","NDC","facility","inpatient","0.050000","UN",,"28.59","28.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATROPINE SULFATE 1 MG/10ML IJ SOSY","81000008","CDM","0250","RC","J0461","HCPCS","0409-4911-11","NDC","facility","inpatient","0.100000","ML","JZ","1.39","1.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE 1 MG/10ML IJ SOSY","81000008","CDM","0250","RC","J0461","HCPCS","0409-4911-34","NDC","facility","inpatient","0.100000","ML","JZ","1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE (PF) 0.4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0461","HCPCS","0517-0401-25","NDC","facility","inpatient","0.025000","ML","JZ","1.87","1.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE (PF) 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0461","HCPCS","0517-1010-25","NDC","facility","inpatient","0.010000","ML","JZ","1.05","1.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE 1 MG/10ML IJ SOSY","81000008","CDM","0250","RC","J0461","HCPCS","76329-3339-1","NDC","facility","inpatient","0.155548","ML","JZ","2.09","2.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE (PF) 0.4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0461","HCPCS","0517-1004-01","NDC","facility","inpatient","0.030263","ML",,"2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATROPINE SULFATE (PF) 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0461","HCPCS","0517-1001-01","NDC","facility","inpatient","0.014255","ML","JZ","1.48","1.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BASILIXIMAB 20 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J0480","HCPCS","0078-0331-84","NDC","facility","inpatient","1.061538","UN",,"11250","11250",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BASILIXIMAB 10 MG/2.5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J0480","HCPCS","0078-0393-61","NDC","facility","inpatient","2.000000","UN",,"14000","14000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DICYCLOMINE HCL 10 MG/ML IM SOLN","81000008","CDM","0250","RC","J0500","HCPCS","58914-080-52","NDC","facility","inpatient","2.000000","ML",,"655.66","655.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZTROPINE MESYLATE 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J0515","HCPCS","68382-860-02","NDC","facility","inpatient","0.500000","ML","JZ","102.81","102.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY","81000008","CDM","0250","RC","J0561","HCPCS","60793-702-10","NDC","facility","inpatient","0.166666","ML","JZ","111.74","111.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY","81000008","CDM","0250","RC","J0561","HCPCS","60793-701-10","NDC","facility","inpatient","0.166666","ML",,"152.49","152.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR","81000008","CDM","0250","RC","J0583","HCPCS","71288-427-11","NDC","facility","inpatient","0.004000","UN","JZ","3.12","3.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR","81000008","CDM","0250","RC","J0583","HCPCS","71288-427-10","NDC","facility","inpatient","0.003983","UN","JZ","2.97","2.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR","81000008","CDM","0250","RC","J0583","HCPCS","65293-001-01","NDC","facility","inpatient","0.003993","UN","JZ","19.54","19.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR","81000008","CDM","0250","RC","J0583","HCPCS","16729-275-67","NDC","facility","inpatient","0.004000","UN","JZ","20","20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR","81000008","CDM","0250","RC","J0583","HCPCS","0781-3158-95","NDC","facility","inpatient","0.004000","UN","JZ","18.20","18.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONABOTULINUMTOXINA 100 UNITS IJ SOLR","81000008","CDM","0250","RC","J0585","HCPCS","0023-1145-01","NDC","facility","inpatient","0.162307","UN","JZ","30.53","30.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALCIUM GLUCONATE-NACL 2-0.675 GM/100ML-% IV SOLN","81000008","CDM","0250","RC","J0610","HCPCS","44567-621-01","NDC","facility","inpatient","10.000000","ML",,"30.81","30.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN","81000008","CDM","0250","RC","J0610","HCPCS","44567-620-24","NDC","facility","inpatient","10.000000","ML",,"33.18","33.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE 10 % IV SOLN","81000008","CDM","0250","RC","J0612","HCPCS","63323-360-61","NDC","facility","inpatient","0.098809","ML",,"1.79","1.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE 10 % IV SOLN","81000008","CDM","0250","RC","J0612","HCPCS","63323-360-19","NDC","facility","inpatient","0.123722","ML",,"1.38","1.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE 10 % IV SOLN","81000008","CDM","0250","RC","J0612","HCPCS","63323-360-59","NDC","facility","inpatient","0.106489","ML","JZ","1.00","1.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALCIUM GLUCONATE 10 % IV SOLN","81000008","CDM","0250","RC","J0612","HCPCS","63323-360-19","NDC","facility","inpatient","0.099723","ML","JZ","1.51","1.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALCIUM GLUCONATE 20MG/ML INTERMITTENT (PEDIATRIC) SH","81000008","CDM","0250","RC","J0613","HCPCS","44567-621-24","NDC","facility","inpatient","0.524021","ML",,"1.54","1.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN","81000008","CDM","0250","RC","J0613","HCPCS","44567-620-24","NDC","facility","inpatient","0.528404","ML",,"1.66","1.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CASPOFUNGIN ACETATE 50 MG IV SOLR","81000008","CDM","0250","RC","J0637","HCPCS","0006-3822-10","NDC","facility","inpatient","0.100000","UN","JZ","202.62","202.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CASPOFUNGIN ACETATE 70 MG IV SOLR","81000008","CDM","0250","RC","J0637","HCPCS","0006-3823-10","NDC","facility","inpatient","0.071428","UN","JZ","150.38","150.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CASPOFUNGIN ACETATE 50 MG IV SOLR","81000008","CDM","0250","RC","J0637","HCPCS","63323-356-01","NDC","facility","inpatient","0.100000","UN","JZ","196.07","196.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CASPOFUNGIN ACETATE 50 MG IV SOLR","81000008","CDM","0250","RC","J0637","HCPCS","63323-356-10","NDC","facility","inpatient","0.100000","UN","JZ","202.2","202.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 100 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","67457-528-10","NDC","facility","inpatient","36.000000","ME",,"300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEUCOVORIN CALCIUM 350 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","25021-816-30","NDC","facility","inpatient","50.000000","ME",,"78","78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEUCOVORIN CALCIUM 100 MG/10ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J0640","HCPCS","0143-9554-01","NDC","facility","inpatient","0.380000","UN",,"300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEUCOVORIN CALCIUM 200 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","71288-162-30","NDC","facility","inpatient","0.201277","UN","JZ","109.09","109.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 100 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","67457-528-10","NDC","facility","inpatient","0.173282","UN","JZ","278.57","278.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","63323-710-50","NDC","facility","inpatient","0.206947","UN","JZ","101.47","101.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","25021-816-30","NDC","facility","inpatient","0.133605","UN","JZ","74.76","74.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","25021-815-30","NDC","facility","inpatient","0.164230","UN","JZ","167.71","167.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 100 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","25021-814-30","NDC","facility","inpatient","0.278698","UN","JZ","239.44","239.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 100 MG/10ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J0640","HCPCS","0143-9554-01","NDC","facility","inpatient","0.232514","UN","JZ","207.14","207.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG/20ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J0640","HCPCS","0143-9553-01","NDC","facility","inpatient","0.254382","UN","JZ","67.14","67.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG IJ SOLR","81000008","CDM","0250","RC","J0640","HCPCS","0143-9368-01","NDC","facility","inpatient","0.235000","UN","JZ","60.71","60.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000008","CDM","0250","RC","J0650","HCPCS","70860-451-10","NDC","facility","inpatient","0.094285","UN","JZ","71.03","71.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000008","CDM","0250","RC","J0650","HCPCS","42023-201-01","NDC","facility","inpatient","0.107490","UN","JZ","72.97","72.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOTHYROXINE SODIUM 100 MCG/5ML IV SOLN","81000008","CDM","0250","RC","J0651","HCPCS","63323-885-10","NDC","facility","inpatient","0.495901","ML",,"70.38","70.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOTHYROXINE SODIUM 100 MCG/5ML IV SOLN","81000008","CDM","0250","RC","J0651","HCPCS","63323-885-10","NDC","facility","inpatient","0.747242","ML","JZ","66.64","66.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000008","CDM","0250","RC","J0651","HCPCS","63323-649-07","NDC","facility","inpatient","0.098238","UN","JZ","80.97","80.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOTHYROXINE SODIUM 200 MCG IV SOLR","81000008","CDM","0250","RC","J0651","HCPCS","63323-647-10","NDC","facility","inpatient","0.050000","UN","JZ","65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","63323-472-37","NDC","facility","inpatient","0.066666","ML","JZ","0.15","0.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1162-01","NDC","facility","inpatient","0.100000","ML","JZ","0.96","0.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1159-02","NDC","facility","inpatient","0.232420","ML","JZ","0.44","0.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1159-01","NDC","facility","inpatient","0.206682","ML","JZ","1.65","1.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1162-02","NDC","facility","inpatient","0.100000","ML","JZ","0.25","0.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1165-01","NDC","facility","inpatient","0.066666","ML","JZ","0.5","0.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-3613-01","NDC","facility","inpatient","0.067826","ML","JZ","3.10","3.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-9046-01","NDC","facility","inpatient","0.139245","ML",,"0.34","0.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1752-50","NDC","facility","inpatient","0.248948","ML",,"0.40","0.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1165-02","NDC","facility","inpatient","0.066565","ML",,"0.12","0.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1165-01","NDC","facility","inpatient","0.133333","ML",,"0.28","0.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL 0.5 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1163-01","NDC","facility","inpatient","0.119354","ML",,"0.15","0.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1162-02","NDC","facility","inpatient","0.150450","ML",,"0.24","0.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","55150-172-30","NDC","facility","inpatient","0.080555","ML","JZ","0.19","0.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","55150-169-10","NDC","facility","inpatient","0.100000","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","55150-167-10","NDC","facility","inpatient","0.200000","ML","JZ","0.75","0.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1165-02","NDC","facility","inpatient","0.066565","ML","JZ","0.12","0.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL 0.25 % IJ SOLN","81000008","CDM","0250","RC","J0665","HCPCS","0409-1160-01","NDC","facility","inpatient","0.214862","ML",,"0.49","0.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN SODIUM 10 G IJ SOLR","81000008","CDM","0250","RC","J0688","HCPCS","0143-9983-03","NDC","facility","inpatient","0.050000","UN",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0688","HCPCS","0143-9924-90","NDC","facility","inpatient","0.519165","UN",,"37.45","37.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN SODIUM 500 MG IJ SOLR","81000008","CDM","0250","RC","J0688","HCPCS","0143-9923-90","NDC","facility","inpatient","0.150000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0688","HCPCS","0143-9924-90","NDC","facility","inpatient","0.476201","UN","JZ","33.53","33.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN 500 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0690","HCPCS","0781-3450-95","NDC","facility","inpatient","50.000000","ML",,"63.56","63.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0690","HCPCS","60505-6231-5","NDC","facility","inpatient","0.262441","UN","JZ","18.77","18.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0690","HCPCS","60505-6231-0","NDC","facility","inpatient","25.680272","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-%(50ML) IV SOLR","81000008","CDM","0250","RC","J0690","HCPCS","0264-3105-11","NDC","facility","inpatient","0.282643","UN","JZ","31.02","31.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0690","HCPCS","0143-9924-90","NDC","facility","inpatient","0.500000","UN","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0690","HCPCS","0781-3451-96","NDC","facility","inpatient","534.414244","ME",,"26.58","26.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0690","HCPCS","60505-6231-5","NDC","facility","inpatient","5.375000","UN",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0690","HCPCS","0781-3451-96","NDC","facility","inpatient","513.981939","ME","JZ","26.03","26.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN 1,000 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0690","HCPCS","99999-0011-25","NDC","facility","inpatient","27.639015","ML",,"26.45","26.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0692","HCPCS","60505-6147-0","NDC","facility","inpatient","0.257092","UN",,"65.54","65.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0692","HCPCS","60505-6147-4","NDC","facility","inpatient","25.000000","ML",,"65.58","65.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0692","HCPCS","99999-0011-27","NDC","facility","inpatient","25.000000","ML",,"66.04","66.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME HCL 1 G IJ SOLR","81000008","CDM","0250","RC","J0692","HCPCS","60505-6146-4","NDC","facility","inpatient","0.276202","UN","JZ","64.99","64.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0692","HCPCS","60505-6147-0","NDC","facility","inpatient","0.290726","UN","JZ","64.24","64.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0692","HCPCS","60505-6147-4","NDC","facility","inpatient","0.500000","GM","JZ","65.58","65.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFEPIME 1000MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0692","HCPCS","60505-6146-0","NDC","facility","inpatient","0.243508","UN","JZ","64.62","64.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFEPIME 1000MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0692","HCPCS","60505-6146-0","NDC","facility","inpatient","0.511575","UN",,"71.16","71.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME HCL 1 G IJ SOLR","81000008","CDM","0250","RC","J0692","HCPCS","60505-6146-4","NDC","facility","inpatient","25.000000","ML",,"71.17","71.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN SODIUM 1 G IV SOLR","81000008","CDM","0250","RC","J0694","HCPCS","0143-9878-25","NDC","facility","inpatient","0.250000","GM",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN (MEFOXIN) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0694","HCPCS","25021-110-20","NDC","facility","inpatient","0.557142","UN",,"42","42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN (MEFOXIN) 1000MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0694","HCPCS","44567-245-25","NDC","facility","inpatient","1.000000","UN",,"83.58","83.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN (MEFOXIN) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0694","HCPCS","44567-246-25","NDC","facility","inpatient","0.517699","UN",,"83.79","83.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN (MEFOXIN) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0694","HCPCS","99999-0011-18","NDC","facility","inpatient","50.000000","ML",,"78.75","78.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN (MEFOXIN) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0694","HCPCS","0143-9877-25","NDC","facility","inpatient","50.000000","ML",,"83.16","83.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN (MEFOXIN) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0694","HCPCS","0143-9877-25","NDC","facility","inpatient","0.990401","GM","JZ","77.79","77.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFOXITIN (MEFOXIN) 1000MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0694","HCPCS","25021-109-10","NDC","facility","inpatient","1.000000","UN","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR","81000008","CDM","0250","RC","J0695","HCPCS","67919-030-01","NDC","facility","inpatient","0.066000","UN","JZ","43.31","43.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0143-9856-25","NDC","facility","inpatient","0.129709","UN",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 1000 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0409-7332-01","NDC","facility","inpatient","0.263288","UN",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE 1GM/50ML D5W (ADV)","81000008","CDM","0250","RC","J0696","HCPCS","0409-7333-04","NDC","facility","inpatient","18.055555","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0409-7335-03","NDC","facility","inpatient","0.131152","UN",,"9.37","9.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 500 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0409-7338-01","NDC","facility","inpatient","0.500000","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0781-3209-95","NDC","facility","inpatient","0.132659","UN",,"74.27","74.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 1000 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0781-9328-85","NDC","facility","inpatient","14.772727","ML",,"72.42","72.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 1000 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","44567-701-25","NDC","facility","inpatient","0.250000","UN",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZZ CEFTRIAXONE (ROCEPHIN) 1 GM (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","99999-0001-31","NDC","facility","inpatient","250.000000","ME",,"74.75","74.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","99999-0011-24","NDC","facility","inpatient","62.500000","ML",,"74.27","74.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE SODIUM 2 G IJ SOLR","81000008","CDM","0250","RC","J0696","HCPCS","44567-702-25","NDC","facility","inpatient","0.125000","UN",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0143-9856-25","NDC","facility","inpatient","0.137142","UN","JZ","9.95","9.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0696","HCPCS","0143-9857-25","NDC","facility","inpatient","0.250000","UN","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 1000 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0409-7332-01","NDC","facility","inpatient","0.291554","UN","JZ","14.64","14.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0409-7335-03","NDC","facility","inpatient","0.151371","UN","JZ","10.68","10.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 500 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0409-7338-01","NDC","facility","inpatient","0.424071","UN","JZ","46.88","46.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J0696","HCPCS","0781-3208-95","NDC","facility","inpatient","257.751937","ME","JZ","70.95","70.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","0781-3209-95","NDC","facility","inpatient","0.127675","UN","JZ","73.12","73.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 1000 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0696","HCPCS","44567-701-25","NDC","facility","inpatient","0.238000","UN","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE SODIUM 2 G IJ SOLR","81000008","CDM","0250","RC","J0696","HCPCS","44567-702-25","NDC","facility","inpatient","0.123421","UN","JZ","9.87","9.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE SODIUM 2 G IJ SOLR","81000008","CDM","0250","RC","J0696","HCPCS","60505-6149-4","NDC","facility","inpatient","0.125000","UN","JZ","74.19","74.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFIDEROCOL SULFATE TOSYLATE 1000 MG/11.2ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J0699","HCPCS","59630-266-01","NDC","facility","inpatient","0.011428","UN","JZ","12.77","12.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFIDEROCOL SULFATE TOSYLATE 1 G IV SOLR","81000008","CDM","0250","RC","J0699","HCPCS","59630-266-10","NDC","facility","inpatient","0.010341","UN","JZ","13.12","13.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP","81000008","CDM","0250","RC","J0702","HCPCS","0517-0720-01","NDC","facility","inpatient","1.127819","ML",,"91.73","91.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP","81000008","CDM","0250","RC","J0702","HCPCS","78206-118-01","NDC","facility","inpatient","1.071428","ML",,"69.86","69.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CAFFEINE CITRATE 60 MG/3ML IV SOLN","81000008","CDM","0250","RC","J0706","HCPCS","25021-601-03","NDC","facility","inpatient","0.197606","ML","JZ","35.70","35.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CAFFEINE CITRATE 60 MG/3ML IV SOLN","81000008","CDM","0250","RC","J0706","HCPCS","51754-0500-1","NDC","facility","inpatient","0.212989","ML","JZ","33.08","33.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CAFFEINE CITRATE 60 MG/3ML IV SOLN","81000008","CDM","0250","RC","J0706","HCPCS","63323-407-03","NDC","facility","inpatient","0.186086","ML","JZ","31.39","31.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CAFFEINE CITRATE 60 MG/3ML IV SOLN","81000008","CDM","0250","RC","J0706","HCPCS","72485-104-01","NDC","facility","inpatient","0.203618","ML","JZ","32.40","32.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CAFFEINE CITRATE 60 MG/3ML IV SOLN","81000008","CDM","0250","RC","J0706","HCPCS","99999-0015-41","NDC","facility","inpatient","0.172000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CAFFEINE CITRATE 60 MG/3ML IV SOLN","81000008","CDM","0250","RC","J0706","HCPCS","25021-601-03","NDC","facility","inpatient","0.878055","ML",,"31.54","31.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTAROLINE FOSAMIL 400 MG IV SOLR","81000008","CDM","0250","RC","J0712","HCPCS","0456-0400-10","NDC","facility","inpatient","0.025000","UN","JZ","45.54","45.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTAROLINE FOSAMIL 600 MG IV SOLR","81000008","CDM","0250","RC","J0712","HCPCS","0456-0600-10","NDC","facility","inpatient","0.016665","UN","JZ","30.36","30.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTAROLINE FOSAMIL 400 MG IV SOLR","81000008","CDM","0250","RC","J0712","HCPCS","0456-0400-10","NDC","facility","inpatient","0.025000","UN",,"35.03","35.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTAROLINE FOSAMIL 600 MG IV SOLR","81000008","CDM","0250","RC","J0712","HCPCS","0456-0600-10","NDC","facility","inpatient","0.016666","UN",,"23.35","23.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTAZIDIME (FORTAZ) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0713","HCPCS","44567-236-10","NDC","facility","inpatient","0.250000","UN",,"21","21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTAZIDIME (FORTAZ) 1000MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0713","HCPCS","44567-235-25","NDC","facility","inpatient","0.500000","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTAZIDIME 1 G IJ SOLR","81000008","CDM","0250","RC","J0713","HCPCS","25021-127-20","NDC","facility","inpatient","0.080900","UN","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTAZIDIME (FORTAZ) 1000MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J0713","HCPCS","44567-235-25","NDC","facility","inpatient","0.141895","UN","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTAZIDIME (FORTAZ) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J0713","HCPCS","44567-236-10","NDC","facility","inpatient","0.063142","UN","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR","81000008","CDM","0250","RC","J0714","HCPCS","0456-2700-10","NDC","facility","inpatient","0.241142","UN","JZ","556.73","556.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR","81000008","CDM","0250","RC","J0714","HCPCS","0456-2700-10","NDC","facility","inpatient","0.253703","UN",,"565.12","565.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0736","HCPCS","0781-3289-09","NDC","facility","inpatient","25.000000","ML","JZ","51.98","51.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0736","HCPCS","0781-3290-09","NDC","facility","inpatient","16.666666","ML","JZ","42.23","42.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE 600 MG/4ML IJ SOLN","81000008","CDM","0250","RC","J0736","HCPCS","67457-815-04","NDC","facility","inpatient","2.000000","ML","JZ","25.94","25.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0737","HCPCS","0338-3410-24","NDC","facility","inpatient","50.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0737","HCPCS","0338-3814-24","NDC","facility","inpatient","17.573696","ML","JZ","36.52","36.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0737","HCPCS","43066-993-24","NDC","facility","inpatient","25.000000","ML","JZ","44.8","44.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0737","HCPCS","43066-995-24","NDC","facility","inpatient","16.666666","ML","JZ","36.52","36.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0737","HCPCS","0338-3410-24","NDC","facility","inpatient","21.562400","ML",,"73.51","73.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0737","HCPCS","0338-3612-24","NDC","facility","inpatient","25.769230","ML","JZ","44.8","44.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CIPROFLOXACIN 200MG/100ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J0744","HCPCS","25021-114-82","NDC","facility","inpatient","100.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 400MG/200ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J0744","HCPCS","25021-114-87","NDC","facility","inpatient","103.061224","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 2MG/ML IN D5W IV SOLN (PEDIATRIC) SH","81000008","CDM","0250","RC","J0744","HCPCS","25021-192-82","NDC","facility","inpatient","59.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 2MG/ML IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0250","RC","J0744","HCPCS","0409-4777-49","NDC","facility","inpatient","0.452857","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 200MG/100ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J0744","HCPCS","0409-4777-23","NDC","facility","inpatient","98.076923","ML",,"40.91","40.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 400MG/200ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J0744","HCPCS","0409-3300-01","NDC","facility","inpatient","102.020202","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 400MG/200ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J0744","HCPCS","0409-4777-02","NDC","facility","inpatient","100.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS","81000008","CDM","0250","RC","J0750","HCPCS","0904-7172-07","NDC","facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS","81000008","CDM","0250","RC","J0750","HCPCS","60687-719-95","NDC","facility","inpatient","3.666666","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS","81000008","CDM","0250","RC","J0751","HCPCS","61958-2002-2","NDC","facility","inpatient","1.315789","UN",,"264.28","264.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLISTIMETHATE SODIUM (CBA) 150 MG/2ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J0770","HCPCS","70594-023-01","NDC","facility","inpatient","0.737600","UN",,"161.21","161.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLISTIMETHATE SODIUM (CBA) 150 MG/2ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J0770","HCPCS","70594-023-04","NDC","facility","inpatient","0.775605","UN",,"169.39","169.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0780","HCPCS","0713-0351-25","NDC","facility","inpatient","1.734042","ML",,"73.43","73.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0780","HCPCS","23155-294-41","NDC","facility","inpatient","1.918110","ML",,"75.51","75.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0780","HCPCS","23155-294-42","NDC","facility","inpatient","2.034722","ML",,"75.43","75.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0780","HCPCS","25021-790-02","NDC","facility","inpatient","1.902373","ML",,"74.68","74.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J0780","HCPCS","70860-778-02","NDC","facility","inpatient","2.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COSYNTROPIN 0.25 MG IJ SOLR","81000008","CDM","0250","RC","J0834","HCPCS","0548-5900-00","NDC","facility","inpatient","1.115310","UN",,"807.61","807.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COSYNTROPIN 0.25 MG IJ SOLR","81000008","CDM","0250","RC","J0834","HCPCS","0781-3440-95","NDC","facility","inpatient","1.008512","UN","JZ","578.78","578.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DALBAVANCIN HCL 500 MG/25ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J0875","HCPCS","57970-100-01","NDC","facility","inpatient","0.010000","UN","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 350 MG IV SOLR","81000008","CDM","0250","RC","J0878","HCPCS","25021-179-15","NDC","facility","inpatient","0.002931","UN","JZ","1.45","1.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 350 MG IV SOLR","81000008","CDM","0250","RC","J0878","HCPCS","25021-179-16","NDC","facility","inpatient","0.002857","UN","JZ","1.42","1.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 500 MG IV SOLR","81000008","CDM","0250","RC","J0878","HCPCS","67919-011-01","NDC","facility","inpatient","0.003411","UN","JZ","4.65","4.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 500 MG IV SOLR","81000008","CDM","0250","RC","J0878","HCPCS","71288-016-15","NDC","facility","inpatient","0.002010","UN","JZ","0.47","0.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 350 MG IV SOLR","81000008","CDM","0250","RC","J0878","HCPCS","25021-179-16","NDC","facility","inpatient","0.002857","UN",,"1.45","1.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARGATROBAN 50 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0883","HCPCS","0143-9559-01","NDC","facility","inpatient","1.140350","ML","JZ","23.76","23.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ARGATROBAN 50 MG/50ML IV SOLN","81000008","CDM","0250","RC","J0883","HCPCS","42367-203-84","NDC","facility","inpatient","1.000000","ML","JZ","27.24","27.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA 4000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J0885","HCPCS","55513-148-10","NDC","facility","inpatient","0.250000","ML","JZ","121.88","121.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DENOSUMAB 120 MG/1.7ML SC SOLN","81000008","CDM","0250","RC","J0897","HCPCS","55513-730-01","NDC","facility","inpatient","0.014166","ML","JZ","87.5","87.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BORTEZOMIB 3.5 MG IJ SOLR","81000008","CDM","0250","RC","J0941","HCPCS","55150-337-01","NDC","facility","inpatient","0.028571","UN","JZ","16.71","16.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BORTEZOMIB 3.5 MG IJ SOLR","81000008","CDM","0250","RC","J0941","HCPCS","55150-337-01","NDC","facility","inpatient","0.028060","UN",,"16.42","16.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP","81000008","CDM","0250","RC","J1010","HCPCS","0009-3475-03","NDC","facility","inpatient","0.012500","ML","JZ","2.07","2.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP","81000008","CDM","0250","RC","J1010","HCPCS","0703-0031-04","NDC","facility","inpatient","0.025000","ML","JZ","1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP","81000008","CDM","0250","RC","J1040","HCPCS","0009-3475-03","NDC","facility","inpatient","3.666666","ML","JZ","165.68","165.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP","81000008","CDM","0250","RC","J1050","HCPCS","0548-5400-00","NDC","facility","inpatient","0.006666","ML",,"2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP","81000008","CDM","0250","RC","J1050","HCPCS","55150-329-01","NDC","facility","inpatient","0.012000","ML",,"1.91","1.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP","81000008","CDM","0250","RC","J1050","HCPCS","67457-887-01","NDC","facility","inpatient","0.006666","ML",,"1.79","1.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","63323-165-01","NDC","facility","inpatient","0.250000","ML","JZ,RISK","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"DEXAMETHASONE SOD PHOS 4 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J1100","HCPCS","0641-6146-25","NDC","facility","inpatient","0.250000","ML",,"1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","63323-165-01","NDC","facility","inpatient","0.452564","ML",,"11.41","11.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","63323-165-05","NDC","facility","inpatient","0.250000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","67457-421-30","NDC","facility","inpatient","0.268567","ML",,"5.53","5.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","67457-422-54","NDC","facility","inpatient","0.266745","ML",,"4.97","4.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","67457-423-12","NDC","facility","inpatient","0.271780","ML",,"15.96","15.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","70069-021-25","NDC","facility","inpatient","0.094778","ML",,"15.93","15.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","63323-165-30","NDC","facility","inpatient","0.291493","ML",,"6.20","6.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","70069-021-25","NDC","facility","inpatient","0.100000","ML","JZ","9.15","9.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","67457-423-12","NDC","facility","inpatient","0.225150","ML","JZ","22.33","22.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","0641-0367-25","NDC","facility","inpatient","0.100000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","63323-165-01","NDC","facility","inpatient","0.266149","ML","JZ","14.61","14.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","63323-506-01","NDC","facility","inpatient","0.100000","ML","JZ","7.68","7.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1100","HCPCS","67457-421-30","NDC","facility","inpatient","0.250000","ML","JZ","8.04","8.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1110","HCPCS","81284-411-10","NDC","facility","inpatient","1.000000","ML","JZ","538.69","538.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAZOLAMIDE SODIUM 500 MG IJ SOLR","81000008","CDM","0250","RC","J1120","HCPCS","0143-9503-01","NDC","facility","inpatient","0.931818","UN",,"317.63","317.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE SODIUM 500 MG IJ SOLR","81000008","CDM","0250","RC","J1120","HCPCS","23155-313-31","NDC","facility","inpatient","0.555555","UN",,"309.66","309.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE SODIUM 500 MG IJ SOLR","81000008","CDM","0250","RC","J1120","HCPCS","39822-0190-1","NDC","facility","inpatient","0.923076","UN",,"237.79","237.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE SODIUM 500 MG IJ SOLR","81000008","CDM","0250","RC","J1120","HCPCS","67457-853-50","NDC","facility","inpatient","0.763157","UN",,"270.86","270.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1160","HCPCS","0641-1410-35","NDC","facility","inpatient","1.069148","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1160","HCPCS","0641-6184-25","NDC","facility","inpatient","1.250000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1160","HCPCS","70515-260-10","NDC","facility","inpatient","1.200000","ML",,"589.24","589.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYTOIN SODIUM 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1165","HCPCS","42192-614-30","NDC","facility","inpatient","0.977611","ML","JZ","8.36","8.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYTOIN SODIUM 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1165","HCPCS","42192-614-10","NDC","facility","inpatient","1.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYTOIN SODIUM 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1165","HCPCS","42192-614-02","NDC","facility","inpatient","1.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYTOIN SODIUM 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1165","HCPCS","0641-2555-45","NDC","facility","inpatient","1.000000","ML","JZ","4.5","4.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYTOIN SODIUM 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1165","HCPCS","0641-0493-25","NDC","facility","inpatient","1.044642","ML","JZ","36.70","36.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0409-1283-05","NDC","facility","inpatient","0.591168","ML",,"88.97","88.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0409-1283-31","NDC","facility","inpatient","0.973115","ML",,"89.75","89.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0409-1312-30","NDC","facility","inpatient","0.460000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL PF 50 MG/5ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0409-2634-05","NDC","facility","inpatient","0.382352","ML",,"7.94","7.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0409-3365-01","NDC","facility","inpatient","0.704985","ML",,"88.98","88.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0409-4264-01","NDC","facility","inpatient","0.449965","ML",,"89.98","89.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0409-4264-11","NDC","facility","inpatient","0.418343","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL PF 50 MG/5ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0703-0113-03","NDC","facility","inpatient","0.375000","ML",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL PF 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","63323-853-25","NDC","facility","inpatient","0.400000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE 1MG/ML IV PCA (NS) (PREMIX) SH","81000008","CDM","0250","RC","J1170","HCPCS","70092-1117-79","NDC","facility","inpatient","4.819692","ML",,"56.04","56.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL-NACL 30-0.9 MG/30ML-% IV SOSY","81000008","CDM","0250","RC","J1170","HCPCS","70092-1293-49","NDC","facility","inpatient","3.750000","ML",,"18.99","18.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE 1MG/ML NS CADD-SOLIS PCA (PREMIX) (PEDIATRIC) SH","81000008","CDM","0250","RC","J1170","HCPCS","70092-1546-35","NDC","facility","inpatient","7.199211","ML",,"13.75","13.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL-NACL 50-0.9 MG/50ML-% IV SOLN","81000008","CDM","0250","RC","J1170","HCPCS","70092-9546-35","NDC","facility","inpatient","3.846153","ML",,"30.02","30.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE VARIABLE DOSE INJ","81000008","CDM","0250","RC","J1170","HCPCS","99999-0006-43","NDC","facility","inpatient","1.160317","ME",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE 1MG/ML IV PCA (NS) (PREMIX) SH","81000008","CDM","0250","RC","J1170","HCPCS","99999-0026-83","NDC","facility","inpatient","8.035714","ML",,"17.94","17.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0641-6151-25","NDC","facility","inpatient","0.790062","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE VARIABLE DOSE INJ","81000008","CDM","0250","RC","J1170","HCPCS","99999-0006-43","NDC","facility","inpatient","2.000000","ME","PN","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1170","HCPCS","0409-4264-01","NDC","facility","inpatient","0.500000","ML","RISK","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"DEXRAZOXANE HCL 500 MG IV SOLR","81000008","CDM","0250","RC","J1190","HCPCS","72611-716-01","NDC","facility","inpatient","0.360000","UN","JZ","1120.39","1120.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1200","HCPCS","0641-0376-25","NDC","facility","inpatient","0.689197","ML","JZ","74.54","74.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1200","HCPCS","63323-664-01","NDC","facility","inpatient","0.537974","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1200","HCPCS","72485-101-25","NDC","facility","inpatient","0.500000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CHLOROTHIAZIDE SODIUM 500 MG IV SOLR","81000008","CDM","0250","RC","J1205","HCPCS","47335-330-40","NDC","facility","inpatient","0.900000","UN","JZ","675.73","675.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CHLOROTHIAZIDE SODIUM 500 MG IV SOLR","81000008","CDM","0250","RC","J1205","HCPCS","63323-658-20","NDC","facility","inpatient","0.900000","UN",,"1786.2","1786.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROTHIAZIDE SODIUM 500 MG IV SOLR","81000008","CDM","0250","RC","J1205","HCPCS","25021-305-20","NDC","facility","inpatient","0.856741","UN","JZ","419.82","419.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHADONE HCL 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1230","HCPCS","24200027645","NDC","facility","inpatient","1.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1230","HCPCS","67457-217-20","NDC","facility","inpatient","0.138623","ML",,"115.07","115.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOBUTAMINE HCL 250 MG/20ML IV SOLN","81000008","CDM","0250","RC","J1250","HCPCS","0409-2344-01","NDC","facility","inpatient","20.000000","ML","JZ","61.88","61.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOBUTAMINE HCL 250 MG/20ML IV SOLN","81000008","CDM","0250","RC","J1250","HCPCS","0409-2344-02","NDC","facility","inpatient","20.000000","ML","JZ","58.24","58.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1250","HCPCS","0338-1075-02","NDC","facility","inpatient","131.655092","ML",,"156","156",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOBUTAMINE HCL 250 MG/20ML IV SOLN","81000008","CDM","0250","RC","J1250","HCPCS","0409-2344-02","NDC","facility","inpatient","21.025641","ML",,"58.46","58.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1250","HCPCS","0409-2347-31","NDC","facility","inpatient","128.105590","ML",,"64.75","64.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOBUTAMINE HCL 250 MG/20ML IV SOLN","81000008","CDM","0250","RC","J1250","HCPCS","70436-203-80","NDC","facility","inpatient","20.000000","ML",,"54.46","54.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOBUTAMINE HCL 250 MG/20ML IV SOLN","81000008","CDM","0250","RC","J1250","HCPCS","70436-203-82","NDC","facility","inpatient","20.000000","ML",,"54.46","54.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1250","HCPCS","0409-2347-32","NDC","facility","inpatient","44.655041","ML",,"72.70","72.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1265","HCPCS","0409-7809-11","NDC","facility","inpatient","14.375000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOPAMINE-DEXTROSE 3.2-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1265","HCPCS","0409-7810-22","NDC","facility","inpatient","30.127009","ML",,"40.28","40.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1265","HCPCS","0409-7809-22","NDC","facility","inpatient","13.529411","ML","JZ","63.46","63.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOPAMINE HCL 40 MG/ML IV SOLN","81000008","CDM","0250","RC","J1265","HCPCS","0409-9104-21","NDC","facility","inpatient","1.000000","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1265","HCPCS","0338-1007-02","NDC","facility","inpatient","12.295081","ML",,"63.16","63.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOPAMINE-DEXTROSE 3.2-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1265","HCPCS","0338-1009-02","NDC","facility","inpatient","14.004452","ML",,"8.44","8.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ECULIZUMAB 300 MG/30ML IV SOLN","81000008","CDM","0250","RC","J1300","HCPCS","25682-001-01","NDC","facility","inpatient","1.000000","ML","JZ","391.38","391.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SUTIMLIMAB-JOME 1100 MG/22ML IV SOLN","81000008","CDM","0250","RC","J1302","HCPCS","80203-347-01","NDC","facility","inpatient","0.200000","ML","JZ","30.76","30.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RAVULIZUMAB-CWVZ 300 MG/3ML IV SOLN","81000008","CDM","0250","RC","J1303","HCPCS","25682-025-01","NDC","facility","inpatient","0.100000","ML","JZ","384.24","384.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOPROSTENOL SODIUM 1.5 MG IV SOLR","81000008","CDM","0250","RC","J1325","HCPCS","0173-0519-00","NDC","facility","inpatient","0.333300","UN",,"126.4","126.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPOPROSTENOL SODIUM 0.5 MG IV SOLR","81000008","CDM","0250","RC","J1325","HCPCS","62756-059-40","NDC","facility","inpatient","1.000000","UN",,"196.7","196.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPOPROSTENOL SODIUM 1.5 MG IV SOLR","81000008","CDM","0250","RC","J1325","HCPCS","62756-060-40","NDC","facility","inpatient","0.350502","UN",,"131.16","131.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPTIFIBATIDE 20 MG/10ML IV SOLN","81000008","CDM","0250","RC","J1327","HCPCS","0085-1177-01","NDC","facility","inpatient","2.400000","ML","JZ","325","325",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPTIFIBATIDE 20 MG/10ML IV SOLN","81000008","CDM","0250","RC","J1327","HCPCS","67457-629-10","NDC","facility","inpatient","2.127272","ML","JZ","47.2","47.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPTIFIBATIDE 75 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1327","HCPCS","0085-1136-01","NDC","facility","inpatient","4.818033","ML",,"204.47","204.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPTIFIBATIDE 75 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1327","HCPCS","55150-218-99","NDC","facility","inpatient","6.666666","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPTIFIBATIDE 75 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1327","HCPCS","67457-631-10","NDC","facility","inpatient","6.666666","ML",,"52","52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPTIFIBATIDE 75 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1327","HCPCS","70436-027-80","NDC","facility","inpatient","6.666666","ML",,"156.27","156.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERTAPENEM SODIUM 1 G IJ SOLR","81000008","CDM","0250","RC","J1335","HCPCS","0006-3843-71","NDC","facility","inpatient","0.500000","UN","JZ","492.26","492.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERTAPENEM 1,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J1335","HCPCS","55150-282-20","NDC","facility","inpatient","0.576335","UN","JZ","228.13","228.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERTAPENEM 1,000MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J1335","HCPCS","55150-282-20","NDC","facility","inpatient","0.522130","UN",,"230.53","230.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR","81000008","CDM","0250","RC","J1364","HCPCS","0409-6482-01","NDC","facility","inpatient","0.443684","UN",,"314.16","314.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TBO-FILGRASTIM 300 MCG/0.5ML SC SOSY","81000008","CDM","0250","RC","J1447","HCPCS","63459-910-11","NDC","facility","inpatient","0.001666","ML","JZ","5.00","5.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J1450","HCPCS","0338-6045-37","NDC","facility","inpatient","100.000000","ML",,"87.5","87.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J1450","HCPCS","0409-4688-12","NDC","facility","inpatient","100.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J1450","HCPCS","25021-184-66","NDC","facility","inpatient","100.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J1450","HCPCS","25021-184-67","NDC","facility","inpatient","101.639344","ML",,"37.23","37.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J1450","HCPCS","25021-184-82","NDC","facility","inpatient","101.179941","ML",,"75.6","75.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J1450","HCPCS","25021-184-87","NDC","facility","inpatient","103.441890","ML",,"58.75","58.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J1450","HCPCS","70655-002-06","NDC","facility","inpatient","123.076923","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J1450","HCPCS","70655-088-06","NDC","facility","inpatient","124.242424","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOMEPIZOLE 1 GM/ML IV SOLN","81000008","CDM","0250","RC","J1451","HCPCS","67457-211-02","NDC","facility","inpatient","0.014976","ML","JZ","50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J1453","HCPCS","0006-3061-00","NDC","facility","inpatient","0.006666","UN","JZ","13.39","13.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR","81000008","CDM","0250","RC","J1453","HCPCS","16714-248-01","NDC","facility","inpatient","0.007008","UN","JZ","11.31","11.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR","81000008","CDM","0250","RC","J1453","HCPCS","43598-948-11","NDC","facility","inpatient","0.007242","UN","JZ","4.28","4.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J1453","HCPCS","71839-104-01","NDC","facility","inpatient","0.007107","UN","JZ","11.76","11.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0250","RC","J1459","HCPCS","44206-436-05","NDC","facility","inpatient","5.930232","ML","JZ","317.53","317.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0250","RC","J1459","HCPCS","44206-437-10","NDC","facility","inpatient","6.509433","ML","JZ","317.40","317.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0250","RC","J1459","HCPCS","44206-438-20","NDC","facility","inpatient","8.163841","ML","JZ","316.31","316.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0250","RC","J1459","HCPCS","44206-439-40","NDC","facility","inpatient","5.000000","ML","JZ","317.36","317.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0250","RC","J1459","HCPCS","44206-436-05","NDC","facility","inpatient","5.000000","ML",,"325.88","325.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0250","RC","J1459","HCPCS","44206-437-10","NDC","facility","inpatient","5.000000","ML",,"316.70","316.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0250","RC","J1459","HCPCS","44206-438-20","NDC","facility","inpatient","5.000000","ML",,"313.00","313.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - GAMUNEX-C","81000008","CDM","0250","RC","J1561","HCPCS","13533-800-12","NDC","facility","inpatient","5.000000","ML","JZ","251.38","251.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - GAMUNEX-C","81000008","CDM","0250","RC","J1561","HCPCS","13533-800-15","NDC","facility","inpatient","5.000000","ML","JZ","251.39","251.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GANCICLOVIR SODIUM 500 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J1570","HCPCS","70436-089-55","NDC","facility","inpatient","0.502075","UN","JZ","247.75","247.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GANCICLOVIR SODIUM 500 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J1570","HCPCS","63323-315-10","NDC","facility","inpatient","0.484682","UN","JZ","313.71","313.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPATITIS B IMMUNE GLOBULIN 312 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1571","HCPCS","70257-052-11","NDC","facility","inpatient","0.500000","ML","JZ","366.03","366.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPATITIS B IMMUNE GLOBULIN IV SOLN SH","81000008","CDM","0250","RC","J1573","HCPCS","70257-051-51","NDC","facility","inpatient","0.500000","ML","JZ","320.38","320.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GENTAMICIN SULFATE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1580","HCPCS","63323-173-02","NDC","facility","inpatient","6.464000","ML","JZ","155.54","155.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GENTAMICIN IN SALINE 0.8-0.9 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1580","HCPCS","0338-0503-48","NDC","facility","inpatient","106.060606","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN IN SALINE 1-0.9 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1580","HCPCS","0338-0505-48","NDC","facility","inpatient","56.666666","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN SULFATE 40 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1580","HCPCS","63323-010-02","NDC","facility","inpatient","1.572121","ML",,"55.28","55.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN SULFATE 40 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1580","HCPCS","63323-010-20","NDC","facility","inpatient","2.010672","ML",,"26.28","26.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN SULFATE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1580","HCPCS","63323-173-01","NDC","facility","inpatient","1.100000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN IN SALINE 1.2-0.9 MG/ML-% IV SOLN (120MG/100ML)","81000008","CDM","0250","RC","J1580","HCPCS","0338-0507-48","NDC","facility","inpatient","50.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1596","HCPCS","0517-4601-25","NDC","facility","inpatient","0.500000","ML","JZ,RISK","56.88","56.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1596","HCPCS","43547-543-25","NDC","facility","inpatient","0.500000","ML","JZ","22.06","22.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1596","HCPCS","0517-4601-25","NDC","facility","inpatient","0.568651","ML","JZ","56.62","56.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1596","HCPCS","43547-543-01","NDC","facility","inpatient","0.761662","ML","JZ","28.17","28.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL (RDNA) 1 MG IJ SOLR","81000008","CDM","0250","RC","J1610","HCPCS","0169-7065-15","NDC","facility","inpatient","0.500000","ME","JZ","975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0250","RC","J1610","HCPCS","63323-596-13","NDC","facility","inpatient","1.000000","UN","JZ","1329.9","1329.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL (RDNA) 1 MG IJ SOLR","81000008","CDM","0250","RC","J1610","HCPCS","0169-7065-15","NDC","facility","inpatient","0.680181","ME",,"1227.97","1227.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0250","RC","J1611","HCPCS","63323-593-03","NDC","facility","inpatient","1.000000","UN","JZ","1376.45","1376.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL (RDNA) 1 MG/ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J1611","HCPCS","63323-594-03","NDC","facility","inpatient","1.000000","UN","JZ","450","450",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0250","RC","J1611","HCPCS","63323-596-06","NDC","facility","inpatient","1.000000","UN","JZ","975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0250","RC","J1611","HCPCS","63323-596-08","NDC","facility","inpatient","2.333333","UN","JZ","975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0250","RC","J1611","HCPCS","63323-596-11","NDC","facility","inpatient","0.625000","UN","JZ","1105.48","1105.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0250","RC","J1611","HCPCS","63323-596-13","NDC","facility","inpatient","0.812500","UN","JZ","1124.88","1124.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GRANISETRON HCL 1 MG/ML IV SOLN","81000008","CDM","0250","RC","J1626","HCPCS","63323-318-01","NDC","facility","inpatient","0.100000","ML","JZ","16.8","16.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GRANISETRON HCL 1 MG/ML IV SOLN","81000008","CDM","0250","RC","J1626","HCPCS","67457-863-01","NDC","facility","inpatient","0.138095","ML","JZ","8.4","8.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HALOPERIDOL LACTATE 5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1630","HCPCS","67457-426-12","NDC","facility","inpatient","0.633497","ML","JZ","74.52","74.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HALOPERIDOL LACTATE 5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1630","HCPCS","63323-474-01","NDC","facility","inpatient","0.623691","ML",,"74.40","74.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN NA (PORK) LOCK FLSH PF 10 UNIT/ML IV SOLN","81000008","CDM","0250","RC","J1642","HCPCS","64253-222-35","NDC","facility","inpatient","1.000000","ML",,"3.44","3.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) 2 UNITS/ML 0.9% NACL LINE PATENCY DRIP (PREMIX) SH","81000008","CDM","0250","RC","J1644","HCPCS","0338-0424-18","NDC","facility","inpatient","500.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","0409-2723-01","NDC","facility","inpatient","0.199780","ML","JZ","15.57","15.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN (PORCINE) 2 UNITS/ML 0.9% NACL LINE PATENCY DRIP (PREMIX) SH","81000008","CDM","0250","RC","J1644","HCPCS","0409-7620-03","NDC","facility","inpatient","900.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","0641-0400-12","NDC","facility","inpatient","0.210202","ML","JZ","15.06","15.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-276-02","NDC","facility","inpatient","1.064349","ML","JZ","53.83","53.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-523-74","NDC","facility","inpatient","10.000000","ML","JZ","3","3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","71288-403-02","NDC","facility","inpatient","0.209140","ML","JZ","15.00","15.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","0409-2720-01","NDC","facility","inpatient","1.206896","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","0409-2720-02","NDC","facility","inpatient","1.000000","ML",,"3.25","3.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 2000-0.9 UNIT/L-% IV SOLN","81000008","CDM","0250","RC","J1644","HCPCS","0409-7620-59","NDC","facility","inpatient","750.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN","81000008","CDM","0250","RC","J1644","HCPCS","0409-7650-30","NDC","facility","inpatient","11.911949","ML",,"4.56","4.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN","81000008","CDM","0250","RC","J1644","HCPCS","0409-7650-62","NDC","facility","inpatient","11.658031","ML",,"4.74","4.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","25021-402-01","NDC","facility","inpatient","0.198820","ML",,"16.67","16.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-262-01","NDC","facility","inpatient","0.210637","ML",,"14.90","14.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-262-06","NDC","facility","inpatient","0.192307","ML",,"6.72","6.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-517-01","NDC","facility","inpatient","11.840364","ML",,"3.16","3.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-540-01","NDC","facility","inpatient","1.057355","ML",,"31.53","31.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-540-03","NDC","facility","inpatient","1.325600","ML",,"73.26","73.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-540-11","NDC","facility","inpatient","1.057915","ML",,"7.33","7.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-540-13","NDC","facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN TOPICAL SCRUB FOR VENOUS CONGESTION SH","81000008","CDM","0250","RC","J1644","HCPCS","63323-540-15","NDC","facility","inpatient","1.082987","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-540-31","NDC","facility","inpatient","1.000000","ML",,"2.00","2.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 10000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63323-542-01","NDC","facility","inpatient","0.447826","ML",,"11.48","11.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63739-931-28","NDC","facility","inpatient","5.705882","ML",,"17.65","17.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","63739-953-25","NDC","facility","inpatient","0.200000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","67457-372-99","NDC","facility","inpatient","3.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J1644","HCPCS","67457-374-99","NDC","facility","inpatient","0.200000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN 30,000 UNIT/1000 ML 0.9% NACL (CELL SAVER PREMIX)","81000008","CDM","0250","RC","J1644","HCPCS","70092-1281-08","NDC","facility","inpatient","33.333333","ML",,"9.1","9.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN TOPICAL SCRUB FOR VENOUS CONGESTION SH","81000008","CDM","0250","RC","J1644","HCPCS","71288-402-10","NDC","facility","inpatient","1.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-566-21","NDC","facility","inpatient","0.103510","ML",,"12.98","12.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-584-99","NDC","facility","inpatient","0.098726","ML",,"10.41","10.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-586-21","NDC","facility","inpatient","0.101019","ML",,"8.42","8.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 150 MG/ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","63323-589-21","NDC","facility","inpatient","0.066664","ML",,"7.82","7.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","71288-410-80","NDC","facility","inpatient","0.100000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","71288-432-80","NDC","facility","inpatient","0.108695","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","71288-433-82","NDC","facility","inpatient","0.110019","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","71288-434-84","NDC","facility","inpatient","0.098269","ML",,"12.75","12.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","71288-435-86","NDC","facility","inpatient","0.097574","ML",,"10.64","10.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-564-97","NDC","facility","inpatient","0.106846","ML",,"18.77","18.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-559-93","NDC","facility","inpatient","0.106461","ML",,"24.35","24.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-535-87","NDC","facility","inpatient","0.100000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-533-83","NDC","facility","inpatient","0.100000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","0548-5605-00","NDC","facility","inpatient","0.098709","ML","JZ","12.6","12.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","0781-3246-02","NDC","facility","inpatient","0.100000","ML","JZ","19.54","19.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","16714-056-01","NDC","facility","inpatient","0.088786","ML","JZ","16.62","16.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-564-97","NDC","facility","inpatient","0.160000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-566-21","NDC","facility","inpatient","0.117021","ML","JZ","12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","63323-584-99","NDC","facility","inpatient","0.134042","ML","JZ","9.57","9.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","63323-655-21","NDC","facility","inpatient","0.061666","ML","JZ","7.18","7.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","71288-433-82","NDC","facility","inpatient","0.100000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","71288-434-84","NDC","facility","inpatient","0.100000","ML","JZ","12.59","12.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","71288-435-86","NDC","facility","inpatient","0.100000","ML","JZ","10.71","10.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","0075-0620-40","NDC","facility","inpatient","0.100000","ML",,"20.84","20.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","0075-0621-60","NDC","facility","inpatient","0.100000","ML",,"20.86","20.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","0075-0622-80","NDC","facility","inpatient","0.096250","ML",,"20.08","20.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 100 MG/ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","0075-0623-00","NDC","facility","inpatient","0.100000","ML",,"20.86","20.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","0075-0624-30","NDC","facility","inpatient","0.100000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","0781-3246-02","NDC","facility","inpatient","0.107972","ML",,"19.55","19.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","0781-3256-66","NDC","facility","inpatient","0.100000","ML",,"19.56","19.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 150 MG/ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","0781-3299-05","NDC","facility","inpatient","0.066665","ML",,"18.17","18.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","16714-036-10","NDC","facility","inpatient","0.101872","ML",,"16.30","16.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","0548-5601-00","NDC","facility","inpatient","0.106315","ML","JZ","24.82","24.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","0075-0622-80","NDC","facility","inpatient","0.098620","ML","JZ","20.58","20.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0250","RC","J1650","HCPCS","0075-0621-60","NDC","facility","inpatient","0.100000","ML","JZ","20.86","20.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY","81000008","CDM","0250","RC","J1650","HCPCS","0075-0620-40","NDC","facility","inpatient","0.110000","ML","JZ","20.84","20.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN","81000008","CDM","0250","RC","J1652","HCPCS","55111-678-02","NDC","facility","inpatient","0.100000","ML","JZ","75.01","75.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN","81000008","CDM","0250","RC","J1652","HCPCS","55111-679-10","NDC","facility","inpatient","0.040000","ML","JZ","83.60","83.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN","81000008","CDM","0250","RC","J1652","HCPCS","55111-678-10","NDC","facility","inpatient","0.100000","ML",,"71.05","71.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FONDAPARINUX SODIUM 2.5 MG/0.2ML SC SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J1652","HCPCS","55111-680-10","NDC","facility","inpatient","0.093333","ML",,"55.73","55.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR","81000008","CDM","0250","RC","J1720","HCPCS","0009-0011-04","NDC","facility","inpatient","0.427186","UN","JZ","98.20","98.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR","81000008","CDM","0250","RC","J1720","HCPCS","0009-0013-05","NDC","facility","inpatient","0.360000","UN","JZ","106.98","106.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLIXIMAB 100 MG IV SOLR","81000008","CDM","0250","RC","J1745","HCPCS","57894-160-01","NDC","facility","inpatient","0.100000","UN","JZ","171","171",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLIXIMAB 100 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J1745","HCPCS","57894-030-01","NDC","facility","inpatient","0.100000","UN","JZ","312.5","312.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0250","RC","J1756","HCPCS","49230-534-10","NDC","facility","inpatient","0.050000","ML","JZ","2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0250","RC","J1756","HCPCS","0517-2340-01","NDC","facility","inpatient","0.057783","ML",,"3.80","3.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0250","RC","J1756","HCPCS","0517-2340-10","NDC","facility","inpatient","0.061158","ML",,"3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0250","RC","J1756","HCPCS","49230-534-10","NDC","facility","inpatient","0.060091","ML",,"2.81","2.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPRANOLOL HCL 1 MG/ML IV SOLN","81000008","CDM","0250","RC","J1800","HCPCS","0143-9872-10","NDC","facility","inpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESMOLOL HCL-SODIUM CHLORIDE 2000 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1805","HCPCS","10019-075-87","NDC","facility","inpatient","0.500000","ML","JZ","12.30","12.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ESMOLOL HCL 100 MG/10ML IV SOLN","81000008","CDM","0250","RC","J1805","HCPCS","10019-120-01","NDC","facility","inpatient","1.062105","ML","JZ","13.96","13.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ESMOLOL HCL-SODIUM CHLORIDE 2000 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1805","HCPCS","25021-309-82","NDC","facility","inpatient","0.504494","ML","JZ","4.88","4.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ESMOLOL HCL 100 MG/10ML IV SOLN","81000008","CDM","0250","RC","J1805","HCPCS","67457-182-10","NDC","facility","inpatient","0.910000","ML","JZ","30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ESMOLOL HCL 100 MG/10ML IV SOLN","81000008","CDM","0250","RC","J1805","HCPCS","10019-120-01","NDC","facility","inpatient","1.000000","ML","JZ,RISK","25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"INSULIN REG HUMAN 100 UNITS/100ML NS IV DRIP GEN MED (PREMIX) SH","81000008","CDM","0250","RC","J1815","HCPCS","0338-0126-12","NDC","facility","inpatient","5.000000","ML",,"0.5","0.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ISAVUCONAZONIUM SULFATE 372 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J1833","HCPCS","0469-0420-01","NDC","facility","inpatient","0.004121","UN","JZ","6.18","6.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","0338-1055-48","NDC","facility","inpatient","2.092753","ML","JZ","1.50","1.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","0409-0152-24","NDC","facility","inpatient","2.077325","ML","JZ","1.50","1.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","0409-7811-24","NDC","facility","inpatient","2.249179","ML","JZ","1.53","1.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","25021-131-82","NDC","facility","inpatient","2.000000","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","47335-993-01","NDC","facility","inpatient","2.044943","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","80830-2465-1","NDC","facility","inpatient","2.050632","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","0338-1055-48","NDC","facility","inpatient","2.779016","ML",,"2.47","2.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","0409-0152-24","NDC","facility","inpatient","3.035048","ML",,"3.26","3.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","0409-7811-24","NDC","facility","inpatient","4.400000","ML",,"1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","47335-993-01","NDC","facility","inpatient","1.932692","ML",,"5.05","5.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1836","HCPCS","80830-2465-1","NDC","facility","inpatient","1.983870","ML",,"3.63","3.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","63323-161-01","NDC","facility","inpatient","1.019284","ML","JZ","70.97","70.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","63323-162-01","NDC","facility","inpatient","0.521021","ML","JZ","40.82","40.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN","81000008","CDM","0250","RC","J1885","HCPCS","63323-162-02","NDC","facility","inpatient","0.500000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","70860-700-01","NDC","facility","inpatient","0.959255","ML","JZ","50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","72266-118-25","NDC","facility","inpatient","0.512165","ML","JZ","40.00","40.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","72611-722-25","NDC","facility","inpatient","0.500000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","63323-162-01","NDC","facility","inpatient","0.785714","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC VARIABLE DOSE INJ","81000008","CDM","0250","RC","J1885","HCPCS","99999-0006-45","NDC","facility","inpatient","20.084745","ME",,"67.63","67.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC VARIABLE DOSE INJ (PEDIATRIC) SH","81000008","CDM","0250","RC","J1885","HCPCS","99999-0007-56","NDC","facility","inpatient","28.950000","ME",,"60.29","60.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","62332-600-01","NDC","facility","inpatient","0.511220","ML","JZ","39.51","39.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN","81000008","CDM","0250","RC","J1885","HCPCS","0409-3796-01","NDC","facility","inpatient","0.500000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","0338-0072-25","NDC","facility","inpatient","0.508089","ML","JZ","39.31","39.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1885","HCPCS","0409-3793-01","NDC","facility","inpatient","1.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J1920","HCPCS","0409-2267-20","NDC","facility","inpatient","1.480000","ML",,"12.84","12.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J1920","HCPCS","0409-2339-34","NDC","facility","inpatient","1.158288","ML",,"35.72","35.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J1920","HCPCS","36000-322-01","NDC","facility","inpatient","1.266666","ML",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5 MG/ML IV SOLN","81000008","CDM","0250","RC","J1920","HCPCS","36000-322-02","NDC","facility","inpatient","1.000000","ML",,"1.25","1.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J1920","HCPCS","69374-946-34","NDC","facility","inpatient","1.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J1920","HCPCS","72266-102-01","NDC","facility","inpatient","3.400000","ML",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5 MG/ML IV SOLN","81000008","CDM","0250","RC","J1920","HCPCS","72266-103-01","NDC","facility","inpatient","1.000000","ML",,"1.26","1.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J1921","HCPCS","0143-9622-01","NDC","facility","inpatient","1.000000","ML",,"6.25","6.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANREOTIDE ACETATE 120 MG/0.5ML SC SOLN","81000008","CDM","0250","RC","J1932","HCPCS","69097-870-67","NDC","facility","inpatient","0.004166","ML","JZ","133.39","133.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","0641-6007-10","NDC","facility","inpatient","2.067973","ML",,"6.14","6.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","0641-6008-10","NDC","facility","inpatient","2.076420","ML",,"19.14","19.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","65219-570-01","NDC","facility","inpatient","2.038004","ML",,"19.67","19.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","65219-570-04","NDC","facility","inpatient","2.172506","ML",,"12.83","12.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","65219-572-01","NDC","facility","inpatient","2.000000","ML",,"10.05","10.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","65219-572-10","NDC","facility","inpatient","2.011007","ML",,"6.04","6.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","68462-470-40","NDC","facility","inpatient","2.000000","ML",,"9.59","9.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","68462-470-54","NDC","facility","inpatient","2.027833","ML",,"5.13","5.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","70860-405-41","NDC","facility","inpatient","2.075769","ML",,"21.22","21.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","70860-406-10","NDC","facility","inpatient","2.040040","ML",,"6.42","6.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","70860-406-41","NDC","facility","inpatient","2.000000","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","72205-101-01","NDC","facility","inpatient","2.026512","ML",,"20.57","20.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","72205-101-07","NDC","facility","inpatient","2.000000","ML",,"12.25","12.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","72205-102-01","NDC","facility","inpatient","2.000000","ML",,"10.71","10.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1939","HCPCS","72205-102-07","NDC","facility","inpatient","2.000000","ML",,"5.55","5.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","0409-6102-02","NDC","facility","inpatient","1.961428","ML","JZ","67.98","67.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","0409-6102-04","NDC","facility","inpatient","2.054281","ML","JZ","31.11","31.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","0409-6102-10","NDC","facility","inpatient","2.056445","ML","JZ","15.22","15.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","16729-500-08","NDC","facility","inpatient","2.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","23155-473-41","NDC","facility","inpatient","1.988372","ML","JZ","64.77","64.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","23155-473-42","NDC","facility","inpatient","2.000000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","25021-311-02","NDC","facility","inpatient","1.507692","ML","JZ","41.67","41.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","25021-311-10","NDC","facility","inpatient","2.000000","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","36000-282-25","NDC","facility","inpatient","2.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","36000-284-25","NDC","facility","inpatient","2.000000","ML","JZ","15.83","15.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","63323-280-02","NDC","facility","inpatient","1.980952","ML","JZ","62.52","62.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","63323-280-10","NDC","facility","inpatient","2.000000","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","70860-302-04","NDC","facility","inpatient","2.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","70860-302-41","NDC","facility","inpatient","2.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","70860-302-43","NDC","facility","inpatient","2.000000","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","71288-203-04","NDC","facility","inpatient","2.000000","ML","JZ","28.12","28.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","71288-203-05","NDC","facility","inpatient","2.000000","ML","JZ","31.25","31.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10MG/ML IV SOLN (PEDIATRIC) SH","81000008","CDM","0250","RC","J1940","HCPCS","99999-0012-28","NDC","facility","inpatient","2.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","0409-6102-02","NDC","facility","inpatient","15.116000","ML",,"71.46","71.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","0409-6102-04","NDC","facility","inpatient","528.400000","ML",,"26.52","26.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J1940","HCPCS","0409-6102-10","NDC","facility","inpatient","4.750000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 15MG/ML IN NACL IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0250","RC","J1953","HCPCS","43598-637-10","NDC","facility","inpatient","0.736656","ML",,"3.77","3.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 15MG/ML IN NACL IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0250","RC","J1953","HCPCS","55150-248-47","NDC","facility","inpatient","0.752272","ML",,"6.70","6.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 100MG/ML IV SYRINGE LOADING DOSE SH","81000008","CDM","0250","RC","J1953","HCPCS","0409-1886-02","NDC","facility","inpatient","0.108832","ML",,"0.64","0.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM 100MG/ML IV SYRINGE LOADING DOSE SH","81000008","CDM","0250","RC","J1953","HCPCS","0409-1886-02","NDC","facility","inpatient","0.103438","ML","JZ","0.83","0.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1953","HCPCS","43598-635-10","NDC","facility","inpatient","2.000000","ML","JZ","3.11","3.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1953","HCPCS","43598-636-10","NDC","facility","inpatient","1.007181","ML","JZ","2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1953","HCPCS","44567-503-01","NDC","facility","inpatient","0.666666","ML","JZ","0.85","0.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1953","HCPCS","67457-255-10","NDC","facility","inpatient","2.500000","ML","JZ","2.35","2.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1953","HCPCS","67457-265-10","NDC","facility","inpatient","1.229885","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1953","HCPCS","67457-266-10","NDC","facility","inpatient","0.666666","ML","JZ","1.48","1.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN","81000008","CDM","0250","RC","J1953","HCPCS","70860-603-82","NDC","facility","inpatient","1.000000","ML","JZ","4.37","4.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM 15MG/ML IN NACL IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0250","RC","J1953","HCPCS","43598-637-10","NDC","facility","inpatient","0.666666","ML","JZ","2.08","2.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOFLOXACIN 750MG/150ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J1956","HCPCS","0143-9720-24","NDC","facility","inpatient","55.555555","ML","JZ","25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOFLOXACIN 500MG/100ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J1956","HCPCS","0143-9721-24","NDC","facility","inpatient","54.166666","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOFLOXACIN 250MG/50ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J1956","HCPCS","0143-9722-24","NDC","facility","inpatient","50.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOFLOXACIN 750MG/150ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J1956","HCPCS","0143-9720-24","NDC","facility","inpatient","294.444444","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 250MG/50ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J1956","HCPCS","25021-132-81","NDC","facility","inpatient","50.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 500MG/100ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J1956","HCPCS","25021-132-82","NDC","facility","inpatient","50.000000","ML",,"46.2","46.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 750MG/150ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0250","RC","J1956","HCPCS","25021-132-83","NDC","facility","inpatient","50.000000","ML",,"30.8","30.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (CARDIAC) 50 MG/5ML IV SOSY","81000008","CDM","0250","RC","J2001","HCPCS","0409-4904-34","NDC","facility","inpatient","5.000000","ML",,"30.23","30.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (CARDIAC) 50 MG/5ML IV SOSY","81000008","CDM","0250","RC","J2001","HCPCS","0409-9137-05","NDC","facility","inpatient","0.970588","ML",,"20.20","20.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","55150-161-02","NDC","facility","inpatient","1.000000","ML",,"20.79","20.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","55150-163-30","NDC","facility","inpatient","0.493217","ML",,"2.87","2.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-201-10","NDC","facility","inpatient","1.023645","ML",,"6.89","6.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-202-01","NDC","facility","inpatient","0.500000","ML",,"16.67","16.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-202-02","NDC","facility","inpatient","0.498165","ML",,"13.19","13.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-485-27","NDC","facility","inpatient","2.443529","ML",,"6.22","6.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-486-17","NDC","facility","inpatient","0.500000","ML",,"3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-486-27","NDC","facility","inpatient","0.243901","ML",,"1.8","1.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-492-27","NDC","facility","inpatient","3.055000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-492-37","NDC","facility","inpatient","0.100000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-492-57","NDC","facility","inpatient","21.800000","ML",,"7.31","7.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1.5 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-493-97","NDC","facility","inpatient","0.626951","ML",,"10.00","10.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-495-27","NDC","facility","inpatient","2.650000","ML",,"13.95","13.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","73293-0001-2","NDC","facility","inpatient","1.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY","81000008","CDM","0250","RC","J2001","HCPCS","76329-3390-1","NDC","facility","inpatient","0.432073","ML",,"7.41","7.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY","81000008","CDM","0250","RC","J2001","HCPCS","0409-4903-34","NDC","facility","inpatient","0.500000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1.5 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-4776-01","NDC","facility","inpatient","1.111111","ML",,"2.84","2.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-4277-01","NDC","facility","inpatient","0.718905","ML",,"1.86","1.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","73293-0001-1","NDC","facility","inpatient","0.951851","ML","JZ","65.93","65.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","73293-0001-2","NDC","facility","inpatient","0.709852","ML","JZ","39.70","39.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-495-27","NDC","facility","inpatient","0.500000","ML","JZ,RISK","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"LIDOCAINE IN D5W 8-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0264-9598-20","NDC","facility","inpatient","1.250000","ML",,"0.38","0.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE IN D5W 8-5 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0338-0411-02","NDC","facility","inpatient","1.330645","ML",,"0.38","0.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN (ET)","81000008","CDM","0250","RC","J2001","HCPCS","0409-1323-15","NDC","facility","inpatient","0.428571","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-2066-05","NDC","facility","inpatient","5.450000","ML",,"10.71","10.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-4276-01","NDC","facility","inpatient","1.096385","ML",,"4.01","4.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-4276-02","NDC","facility","inpatient","1.000000","ML",,"2.05","2.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 4 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-4283-01","NDC","facility","inpatient","0.312500","ML",,"2.70","2.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-495-27","NDC","facility","inpatient","0.556754","ML","JZ","15.26","15.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-495-07","NDC","facility","inpatient","1.236842","ML","JZ","3.70","3.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-492-57","NDC","facility","inpatient","1.219879","ML","JZ","13.42","13.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-492-37","NDC","facility","inpatient","1.164315","ML","JZ","4.13","4.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-2066-05","NDC","facility","inpatient","0.546333","ML","JZ","9.70","9.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-4279-02","NDC","facility","inpatient","1.272189","ML","JZ","3.53","3.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","0409-4282-02","NDC","facility","inpatient","0.508648","ML","JZ","2.21","2.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","55150-161-02","NDC","facility","inpatient","0.684619","ML","JZ","60.36","60.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","55150-162-05","NDC","facility","inpatient","0.902531","ML","JZ","19.04","19.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","55150-163-30","NDC","facility","inpatient","1.396967","ML","JZ","4.67","4.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","55150-165-05","NDC","facility","inpatient","2.500000","ML","JZ","2.52","2.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-201-02","NDC","facility","inpatient","1.007092","ML","JZ","16.66","16.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0250","RC","J2001","HCPCS","63323-492-27","NDC","facility","inpatient","0.825238","ML","JZ","55.85","55.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LINEZOLID 600 MG/300ML IV SOLN","81000008","CDM","0250","RC","J2020","HCPCS","0009-5140-04","NDC","facility","inpatient","125.000000","ML",,"66.3","66.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINEZOLID 600 MG/300ML IV SOLN","81000008","CDM","0250","RC","J2020","HCPCS","25021-169-87","NDC","facility","inpatient","100.000000","ML",,"91","91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINEZOLID 600 MG/300ML IV SOLN","81000008","CDM","0250","RC","J2020","HCPCS","57664-683-57","NDC","facility","inpatient","100.000000","ML",,"169","169",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINEZOLID 600 MG/300ML IV SOLN","81000008","CDM","0250","RC","J2020","HCPCS","63323-713-03","NDC","facility","inpatient","100.000000","ML",,"104","104",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINEZOLID 600 MG/300ML IV SOLN","81000008","CDM","0250","RC","J2020","HCPCS","66794-219-63","NDC","facility","inpatient","101.689189","ML",,"53.2","53.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2060","HCPCS","0641-6046-10","NDC","facility","inpatient","0.605000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2060","HCPCS","0409-1985-30","NDC","facility","inpatient","0.841777","ML",,"81.07","81.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2060","HCPCS","0641-6001-25","NDC","facility","inpatient","0.816391","ML",,"82.54","82.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2060","HCPCS","0641-6044-25","NDC","facility","inpatient","0.651285","ML",,"86.35","86.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2060","HCPCS","0641-6048-25","NDC","facility","inpatient","0.628076","ML",,"88.88","88.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MANNITOL 25 % IV SOLN","81000008","CDM","0250","RC","J2150","HCPCS","63323-024-25","NDC","facility","inpatient","49.305732","ML","JZ","47.68","47.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEPERIDINE HCL 25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2175","HCPCS","0409-1176-30","NDC","facility","inpatient","1.314814","ML",,"90.47","90.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEPERIDINE HCL 25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2175","HCPCS","0641-6052-25","NDC","facility","inpatient","0.546875","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEPERIDINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2175","HCPCS","0641-6053-25","NDC","facility","inpatient","0.890625","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEPERIDINE VARIABLE DOSE INJ","81000008","CDM","0250","RC","J2175","HCPCS","99999-0006-48","NDC","facility","inpatient","12.500000","ME",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","63323-508-30","NDC","facility","inpatient","0.102239","UN",,"7.50","7.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 500 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","63323-507-20","NDC","facility","inpatient","0.203894","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","0781-3098-95","NDC","facility","inpatient","0.100665","UN",,"23.68","23.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","55150-208-30","NDC","facility","inpatient","0.100000","UN",,"9.24","9.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","0409-1391-21","NDC","facility","inpatient","0.116091","UN","JZ","16.70","16.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEROPENEM 1 G IV SOLR","81000008","CDM","0250","RC","J2185","HCPCS","0409-1391-22","NDC","facility","inpatient","0.100000","UN","JZ","16.15","16.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","0781-3098-95","NDC","facility","inpatient","0.100000","UN","JZ","23.68","23.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEROPENEM 500 MG/50ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","63323-507-20","NDC","facility","inpatient","0.109649","UN","JZ","52.8","52.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","63323-508-30","NDC","facility","inpatient","0.103265","UN","JZ","4.97","4.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","0409-1391-21","NDC","facility","inpatient","0.104669","UN",,"17.33","17.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2185","HCPCS","0409-3506-01","NDC","facility","inpatient","10.000000","ML",,"23.27","23.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2210","HCPCS","0517-0740-20","NDC","facility","inpatient","1.000000","ML","JZ","236.24","236.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2210","HCPCS","0517-0740-20","NDC","facility","inpatient","1.085106","ML",,"235.97","235.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN 50MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","63323-728-01","NDC","facility","inpatient","0.021702","UN",,"14.59","14.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN 50MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","63323-728-10","NDC","facility","inpatient","0.020000","UN",,"13.28","13.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","63323-729-01","NDC","facility","inpatient","0.010283","UN",,"9.93","9.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","70710-1725-1","NDC","facility","inpatient","0.010740","UN",,"6.08","6.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","25021-191-10","NDC","facility","inpatient","0.010119","UN",,"11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","16714-301-01","NDC","facility","inpatient","0.010000","UN",,"11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","0469-3211-10","NDC","facility","inpatient","0.010000","UN",,"11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN SODIUM 100 MG IV SOLR","81000008","CDM","0250","RC","J2248","HCPCS","70710-1725-6","NDC","facility","inpatient","0.010000","UN","JZ","6.08","6.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN SODIUM 50 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J2248","HCPCS","16714-164-01","NDC","facility","inpatient","0.020000","UN","JZ","14.59","14.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","16714-301-01","NDC","facility","inpatient","0.010000","UN","JZ","11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN SODIUM 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J2248","HCPCS","16714-301-10","NDC","facility","inpatient","0.010000","UN","JZ","11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","25021-191-10","NDC","facility","inpatient","0.011355","UN","JZ","11.24","11.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN SODIUM 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J2248","HCPCS","25021-191-11","NDC","facility","inpatient","0.010000","UN","JZ","11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN 50MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","63323-728-01","NDC","facility","inpatient","0.020000","UN","JZ","12.19","12.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN 50MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","63323-728-10","NDC","facility","inpatient","0.020000","UN","JZ","11.47","11.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","63323-729-01","NDC","facility","inpatient","0.010722","UN","JZ","11.00","11.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN SODIUM 100 MG IV SOLR","81000008","CDM","0250","RC","J2248","HCPCS","63323-729-10","NDC","facility","inpatient","0.011616","UN","JZ","10.62","10.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","70710-1725-1","NDC","facility","inpatient","0.010000","UN","JZ","6.08","6.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2248","HCPCS","0469-3211-10","NDC","facility","inpatient","0.010000","UN","JZ","11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MIDAZOLAM HCL 5 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0409-2308-01","NDC","facility","inpatient","0.312570","ML",,"10.86","10.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2250","HCPCS","0143-9380-01","NDC","facility","inpatient","1.400000","ML",,"1.8","1.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0409-2305-05","NDC","facility","inpatient","1.416666","ML",,"31.09","31.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0409-2305-17","NDC","facility","inpatient","1.065445","ML",,"49.95","49.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 5 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0409-2596-05","NDC","facility","inpatient","0.200000","ML",,"1.8","1.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0641-6056-10","NDC","facility","inpatient","1.717948","ML",,"11.74","11.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0641-6057-10","NDC","facility","inpatient","0.907142","ML",,"22.5","22.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0641-6057-25","NDC","facility","inpatient","1.170103","ML",,"44.54","44.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 5 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0641-6060-10","NDC","facility","inpatient","0.200000","ML",,"2.05","2.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","23155-600-41","NDC","facility","inpatient","0.833333","ML",,"60","60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2250","HCPCS","44567-611-10","NDC","facility","inpatient","2.239130","ML",,"1.8","1.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2250","HCPCS","70092-1030-36","NDC","facility","inpatient","5.000000","ML",,"1.92","1.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J2250","HCPCS","0641-6057-25","NDC","facility","inpatient","1.000000","ML","RISK","45","45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2251","HCPCS","44567-611-10","NDC","facility","inpatient","2.440000","ML",,"1.79","1.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MILRINONE LACTATE 20 MG/20ML IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0143-9709-10","NDC","facility","inpatient","5.000000","ML","JZ","19.28","19.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0143-9719-10","NDC","facility","inpatient","25.047147","ML","JZ","31.85","31.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0338-6010-48","NDC","facility","inpatient","873847.771733","ML","JZ","69.66","69.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MILRINONE LACTATE 20 MG/20ML IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0409-0212-01","NDC","facility","inpatient","5.000000","ML","JZ","30.20","30.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0409-2776-23","NDC","facility","inpatient","25.000000","ML","JZ","33.6","33.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","25021-313-82","NDC","facility","inpatient","25.000000","ML","JZ","27.82","27.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","55150-287-01","NDC","facility","inpatient","25.000000","ML","JZ","31.85","31.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MILRINONE LACTATE 20 MG/20ML IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0143-9710-10","NDC","facility","inpatient","5.000000","ML",,"26.25","26.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0338-6010-48","NDC","facility","inpatient","26.284500","ML",,"56.3","56.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MILRINONE LACTATE 20 MG/20ML IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0409-0212-01","NDC","facility","inpatient","5.000000","ML",,"30.20","30.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MILRINONE LACTATE 20 MG/20ML IV SOLN","81000008","CDM","0250","RC","J2260","HCPCS","0143-9709-10","NDC","facility","inpatient","5.000000","ML",,"19.28","19.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE VARIABLE DOSE INJ","81000008","CDM","0250","RC","J2270","HCPCS","99999-0006-49","NDC","facility","inpatient","10.000000","ME",,"85.87","85.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE-NACL 150-0.9 MG/30ML-% IV SOSY","81000008","CDM","0250","RC","J2270","HCPCS","99999-0025-38","NDC","facility","inpatient","4.370370","ML",,"9.25","9.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE 1MG/ML IV PCA (PREMIX) SH","81000008","CDM","0250","RC","J2270","HCPCS","70092-1613-79","NDC","facility","inpatient","22.000000","ML",,"101.58","101.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE-NACL 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2270","HCPCS","70092-1380-36","NDC","facility","inpatient","15.000000","ML",,"11.92","11.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE-NACL 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J2270","HCPCS","70092-1130-36","NDC","facility","inpatient","10.000000","ML",,"13","13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2270","HCPCS","63323-451-01","NDC","facility","inpatient","1.514285","ML",,"45","45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 2 MG/ML IV SOLN","81000008","CDM","0250","RC","J2270","HCPCS","0409-1890-01","NDC","facility","inpatient","1.330685","ML",,"89.43","89.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 4 MG/ML IV SOLN","81000008","CDM","0250","RC","J2270","HCPCS","0409-1891-01","NDC","facility","inpatient","5.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2270","HCPCS","0409-1893-01","NDC","facility","inpatient","0.683333","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2270","HCPCS","0409-3814-12","NDC","facility","inpatient","15.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2270","HCPCS","0641-6020-10","NDC","facility","inpatient","4.593972","ML",,"114.26","114.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE 4 MG/ML IV SOLN","81000008","CDM","0250","RC","J2270","HCPCS","0641-6125-25","NDC","facility","inpatient","1.307517","ML",,"87.08","87.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2270","HCPCS","0641-6127-25","NDC","facility","inpatient","1.335642","ML",,"45.58","45.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2272","HCPCS","63323-451-01","NDC","facility","inpatient","1.541530","ML",,"46.88","46.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2272","HCPCS","63323-454-01","NDC","facility","inpatient","1.254044","ML",,"86.72","86.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE 4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2272","HCPCS","76045-005-10","NDC","facility","inpatient","1.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2274","HCPCS","0409-3815-12","NDC","facility","inpatient","0.250000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2274","HCPCS","0641-6019-10","NDC","facility","inpatient","1.789784","ML",,"92.19","92.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALBUPHINE HCL 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2300","HCPCS","0409-1463-71","NDC","facility","inpatient","0.382352","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 5 MG/ML IV SOLN","81000008","CDM","0250","RC","J2305","HCPCS","0517-4810-25","NDC","facility","inpatient","0.209819","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NITROGLYCERIN 100MCG/ML INJ","81000008","CDM","0250","RC","J2305","HCPCS","0338-1047-02","NDC","facility","inpatient","2.181518","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 200MCG/ML INJ SH","81000008","CDM","0250","RC","J2305","HCPCS","0338-1049-02","NDC","facility","inpatient","53.064516","ML",,"18.46","18.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 100MCG/ML INJ","81000008","CDM","0250","RC","J2305","HCPCS","0409-1483-02","NDC","facility","inpatient","35.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 4 MG/10ML IJ SOLN","81000008","CDM","0250","RC","J2310","HCPCS","67457-299-10","NDC","facility","inpatient","2.844827","ML",,"169.21","169.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2310","HCPCS","70069-071-01","NDC","facility","inpatient","1.583333","ML",,"85.42","85.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0250","RC","J2310","HCPCS","55150-345-10","NDC","facility","inpatient","1.000000","ML",,"122.07","122.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0250","RC","J2310","HCPCS","55150-345-01","NDC","facility","inpatient","0.980952","ML",,"121.54","121.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2310","HCPCS","67457-292-02","NDC","facility","inpatient","1.003759","ML","JZ","173.08","173.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NALOXONE HCL 4 MG/10ML IJ SOLN","81000008","CDM","0250","RC","J2310","HCPCS","55150-328-01","NDC","facility","inpatient","2.500000","ML",,"186.88","186.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 4 MG/10ML IJ SOLN","81000008","CDM","0250","RC","J2310","HCPCS","55150-328-10","NDC","facility","inpatient","2.500000","ML",,"186.88","186.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2310","HCPCS","0409-1215-01","NDC","facility","inpatient","3.000000","ML","JZ","177.28","177.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0250","RC","J2310","HCPCS","76329-3369-1","NDC","facility","inpatient","0.944604","ML","JZ","117.55","117.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2310","HCPCS","0409-1215-01","NDC","facility","inpatient","1.000000","ML",,"132.97","132.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0250","RC","J2310","HCPCS","0641-6205-01","NDC","facility","inpatient","0.952000","ML",,"119.09","119.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0250","RC","J2310","HCPCS","0641-6205-10","NDC","facility","inpatient","1.000000","ML",,"121.88","121.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2310","HCPCS","36000-308-10","NDC","facility","inpatient","1.574074","ML",,"80.87","80.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0250","RC","J2310","HCPCS","43598-750-11","NDC","facility","inpatient","1.009756","ML",,"119.88","119.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OLANZAPINE 10 MG IM SOLR","81000008","CDM","0250","RC","J2359","HCPCS","31722-308-01","NDC","facility","inpatient","0.070000","UN","JZ","14.34","14.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","81000008","CDM","0250","RC","J2359","HCPCS","0002-7597-01","NDC","facility","inpatient","0.050000","UN","JZ","19.77","19.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYLEPHRINE HCL-NACL 50-0.9 MG/250ML-% IV SOLN","81000008","CDM","0250","RC","J2370","HCPCS","70092-9045-05","NDC","facility","inpatient","4.013503","ML",,"90.76","90.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2370","HCPCS","0641-6142-25","NDC","facility","inpatient","1.190000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2370","HCPCS","0641-6142-25","NDC","facility","inpatient","0.039600","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2371","HCPCS","0641-6142-25","NDC","facility","inpatient","0.002202","ML","JZ","3.72","3.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2371","HCPCS","0641-6142-25","NDC","facility","inpatient","0.002000","ML","JZ,RISK","1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2371","HCPCS","0781-3458-95","NDC","facility","inpatient","0.002000","ML",,"0.08","0.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL-NACL 1-0.9 MG/10ML-% IV SOSY","81000008","CDM","0250","RC","J2371","HCPCS","70092-1046-46","NDC","facility","inpatient","0.213494","ML",,"3.99","3.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL-NACL 50-0.9 MG/250ML-% IV SOLN","81000008","CDM","0250","RC","J2371","HCPCS","70092-9045-05","NDC","facility","inpatient","0.150353","ML",,"0.34","0.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL-NACL 50-0.9 MG/250ML-% IV SOLN","81000008","CDM","0250","RC","J2371","HCPCS","71266-5250-1","NDC","facility","inpatient","0.120183","ML",,"0.09","0.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2371","HCPCS","76014-004-33","NDC","facility","inpatient","0.002000","ML",,"0.08","0.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2371","HCPCS","0641-6142-25","NDC","facility","inpatient","0.002027","ML",,"0.13","0.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROPROCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2401","HCPCS","0143-9209-10","NDC","facility","inpatient","0.012500","ML",,"0.45","0.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROPROCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0250","RC","J2401","HCPCS","63323-477-27","NDC","facility","inpatient","0.050000","ML",,"0.45","0.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROPROCAINE HCL (PF) 3 % IJ SOLN","81000008","CDM","0250","RC","J2401","HCPCS","63323-478-27","NDC","facility","inpatient","0.033333","ML",,"0.31","0.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROPROCAINE HCL (PF) 3 % IJ SOLN","81000008","CDM","0250","RC","J2401","HCPCS","0143-9210-10","NDC","facility","inpatient","0.033333","ML",,"0.31","0.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICARDIPINE 2.5 MG/ML INTERVENTIONAL INJ SOLN","81000008","CDM","0250","RC","J2404","HCPCS","0143-9689-10","NDC","facility","inpatient","0.040000","ML",,"0.84","0.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICARDIPINE HCL IN NACL 40-0.83 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J2404","HCPCS","0143-9633-01","NDC","facility","inpatient","0.539215","ML","JZ","2.44","2.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NICARDIPINE HCL IN NACL 40-0.83 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J2404","HCPCS","10122-325-10","NDC","facility","inpatient","0.500000","ML","JZ","3.05","3.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NICARDIPINE HCL IN NACL 40-0.83 MG/200ML-% IV SOLN","81000008","CDM","0250","RC","J2404","HCPCS","43066-016-10","NDC","facility","inpatient","0.548000","ML","JZ","2.71","2.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","0641-6079-01","NDC","facility","inpatient","0.531047","ML",,"4.70","4.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","0409-4755-03","NDC","facility","inpatient","0.495000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","0641-6078-25","NDC","facility","inpatient","0.531681","ML","JZ","17.70","17.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","60505-6130-5","NDC","facility","inpatient","0.524270","ML","JZ","18.11","18.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","70860-776-02","NDC","facility","inpatient","0.499702","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","0641-6078-25","NDC","facility","inpatient","0.500000","ML","JZ,RISK","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","0641-6078-25","NDC","facility","inpatient","17.916666","ML",,"19.22","19.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","16729-298-05","NDC","facility","inpatient","0.561538","ML",,"4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","23155-549-31","NDC","facility","inpatient","2.500000","ML",,"4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","60505-6130-5","NDC","facility","inpatient","1.269230","ML",,"16.07","16.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0250","RC","J2405","HCPCS","72266-124-01","NDC","facility","inpatient","0.500000","ML",,"4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN","81000008","CDM","0250","RC","J2430","HCPCS","61703-324-18","NDC","facility","inpatient","10.000000","ML","JZ","109.33","109.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN","81000008","CDM","0250","RC","J2430","HCPCS","67457-430-10","NDC","facility","inpatient","10.000000","ML","JZ","210.6","210.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","J2470","HCPCS","0008-0923-55","NDC","facility","inpatient","1.285714","UN",,"69.74","69.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","J2470","HCPCS","25021-751-10","NDC","facility","inpatient","1.030577","UN",,"74.17","74.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","J2470","HCPCS","55150-202-10","NDC","facility","inpatient","1.464138","UN",,"74.77","74.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","J2471","HCPCS","0143-9284-10","NDC","facility","inpatient","1.000000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR","81000008","CDM","0250","RC","J2540","HCPCS","0049-0530-28","NDC","facility","inpatient","0.030297","UN","JZ","12.11","12.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR","81000008","CDM","0250","RC","J2540","HCPCS","0781-6136-94","NDC","facility","inpatient","0.027777","UN","JZ","28.94","28.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR","81000008","CDM","0250","RC","J2540","HCPCS","0049-0520-83","NDC","facility","inpatient","0.054960","UN",,"34.38","34.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN G POTASSIUM 5 MU/10ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J2540","HCPCS","0781-6135-95","NDC","facility","inpatient","0.114285","UN",,"12.7","12.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0409-3379-04","NDC","facility","inpatient","0.250000","UN","JZ","32.76","32.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0409-3385-11","NDC","facility","inpatient","0.348588","UN","JZ","29.28","29.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0409-3390-11","NDC","facility","inpatient","0.259009","UN","JZ","29.28","29.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0781-3113-95","NDC","facility","inpatient","0.347965","UN","JZ","43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0781-3114-95","NDC","facility","inpatient","0.254713","UN","JZ","40.92","40.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0781-9213-90","NDC","facility","inpatient","0.343246","UN","JZ","43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","44567-803-10","NDC","facility","inpatient","0.263081","UN","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","55150-120-30","NDC","facility","inpatient","0.345541","UN","JZ","24.93","24.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","55150-121-50","NDC","facility","inpatient","0.258415","UN","JZ","48.21","48.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","60505-6159-4","NDC","facility","inpatient","0.250000","UN","JZ","38.06","38.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","64679-012-01","NDC","facility","inpatient","0.258394","UN","JZ","48.21","48.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","64679-056-01","NDC","facility","inpatient","1.666666","UN","JZ","50.76","50.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","65219-436-02","NDC","facility","inpatient","0.349862","UN","JZ","25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","72485-403-01","NDC","facility","inpatient","0.354058","UN","JZ","39.99","39.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","72485-404-01","NDC","facility","inpatient","0.250000","UN","JZ","37.98","37.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0409-3378-11","NDC","facility","inpatient","33.333333","ML","JZ","32.28","32.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0206-8855-16","NDC","facility","inpatient","25.000000","ML","JZ","28.84","28.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0206-8854-16","NDC","facility","inpatient","0.369261","UN","JZ","28.89","28.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR","81000008","CDM","0250","RC","J2543","HCPCS","0206-8852-16","NDC","facility","inpatient","0.277428","UN","JZ","34.84","34.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR","81000008","CDM","0250","RC","J2543","HCPCS","0206-8852-16","NDC","facility","inpatient","0.568965","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0206-8854-16","NDC","facility","inpatient","0.442622","UN",,"28.84","28.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN-TAZOBACTAM IN DEX 3-0.375 GM/50ML IV SOLN","81000008","CDM","0250","RC","J2543","HCPCS","0206-8861-02","NDC","facility","inpatient","16.666666","ML",,"5.92","5.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0409-3378-11","NDC","facility","inpatient","185.997641","ML",,"32.23","32.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0409-3385-11","NDC","facility","inpatient","0.333333","UN",,"29.28","29.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0781-3113-95","NDC","facility","inpatient","22.333333","UN",,"43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0781-3114-95","NDC","facility","inpatient","0.250000","UN",,"40.92","40.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 2.25 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","44567-801-10","NDC","facility","inpatient","0.512618","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR","81000008","CDM","0250","RC","J2543","HCPCS","55150-119-30","NDC","facility","inpatient","0.572874","UN",,"50.75","50.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","55150-120-30","NDC","facility","inpatient","0.333333","UN",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 2.25 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","64679-034-01","NDC","facility","inpatient","0.500000","UN",,"50.75","50.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","65219-436-02","NDC","facility","inpatient","0.333333","UN",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 2.25 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J2543","HCPCS","0781-3110-95","NDC","facility","inpatient","0.514045","UN",,"43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENTAMIDINE ISETHIONATE 300 MG IN SOLR","81000008","CDM","0250","RC","J2545","HCPCS","13925-522-01","NDC","facility","inpatient","1.000000","UN","JZ","541.5","541.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENTAMIDINE ISETHIONATE 300 MG IN SOLR","81000008","CDM","0250","RC","J2545","HCPCS","63323-877-15","NDC","facility","inpatient","1.000000","UN","JZ","600.81","600.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PERAMIVIR 200 MG/20ML IV SOLN","81000008","CDM","0250","RC","J2547","HCPCS","72769-181-01","NDC","facility","inpatient","0.100000","ML","JZ","9.64","9.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PERAMIVIR 200 MG/20ML IV SOLN","81000008","CDM","0250","RC","J2547","HCPCS","72769-181-03","NDC","facility","inpatient","0.100000","ML","JZ","7.6","7.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2560","HCPCS","0641-0477-25","NDC","facility","inpatient","0.692333","ML","JZ","211.52","211.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2560","HCPCS","14789-128-07","NDC","facility","inpatient","1.279069","ML","JZ","137.72","137.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2560","HCPCS","42494-416-25","NDC","facility","inpatient","0.621408","ML","JZ","148.42","148.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENOBARBITAL 65MG/ML INJ (PEDIATRIC) SH","81000008","CDM","0250","RC","J2560","HCPCS","14789-127-07","NDC","facility","inpatient","0.236511","ML",,"90.60","90.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2560","HCPCS","42494-415-25","NDC","facility","inpatient","1.963797","ML",,"153.98","153.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2560","HCPCS","0641-0476-25","NDC","facility","inpatient","0.369200","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN-LACTATED RINGERS 30 UNIT/500ML IV SOLN","81000008","CDM","0250","RC","J2590","HCPCS","71285-6039-1","NDC","facility","inpatient","196.969696","ML",,"30.75","30.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 30 UNITS/500 ML LACTATED RINGERS IV DRIP FOR INDUCTION (PREMIX) SH","81000008","CDM","0250","RC","J2590","HCPCS","72196-6039-1","NDC","facility","inpatient","166.666666","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 30 UNITS/500 ML LACTATED RINGERS IV DRIP FOR INDUCTION (PREMIX) SH","81000008","CDM","0250","RC","J2590","HCPCS","99999-0006-31","NDC","facility","inpatient","150.120381","ML",,"390.24","390.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN-LACTATED RINGERS 30 UNIT/500ML IV SOLN","81000008","CDM","0250","RC","J2590","HCPCS","70092-1071-24","NDC","facility","inpatient","198.504983","ML",,"70.23","70.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J2590","HCPCS","63323-012-30","NDC","facility","inpatient","1.285714","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J2590","HCPCS","63323-012-11","NDC","facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J2590","HCPCS","63323-012-10","NDC","facility","inpatient","1.034246","ML",,"8.18","8.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J2590","HCPCS","42023-116-25","NDC","facility","inpatient","0.874774","ML","JZ","57.24","57.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J2590","HCPCS","42023-116-02","NDC","facility","inpatient","0.323308","ML",,"17.75","17.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J2590","HCPCS","63323-012-01","NDC","facility","inpatient","0.777272","ML",,"56.25","56.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J2590","HCPCS","63323-012-02","NDC","facility","inpatient","1.186528","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J2597","HCPCS","55566-2200-0","NDC","facility","inpatient","0.250000","ML","JZ","121.77","121.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J2597","HCPCS","69918-899-01","NDC","facility","inpatient","0.250000","ML","JZ","114.64","114.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J2597","HCPCS","25021-460-01","NDC","facility","inpatient","0.250000","ML",,"106.69","106.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J2597","HCPCS","39822-6250-1","NDC","facility","inpatient","0.245000","ML",,"33.15","33.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J2597","HCPCS","65219-295-10","NDC","facility","inpatient","0.248130","ML",,"29.05","29.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J2597","HCPCS","69918-901-10","NDC","facility","inpatient","0.253442","ML",,"85.29","85.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VASOPRESSIN 20 UNIT/ML IJ SOLN (IO)","81000008","CDM","0250","RC","J2598","HCPCS","42023-164-25","NDC","facility","inpatient","0.050000","ML",,"14.58","14.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VASOPRESSIN 20 UNIT/ML IV SOLN","81000008","CDM","0250","RC","J2598","HCPCS","55150-370-25","NDC","facility","inpatient","0.050000","ML","JZ","29.25","29.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN-SODIUM CHLORIDE 20-0.9 UT/100ML-% IV SOLN","81000008","CDM","0250","RC","J2598","HCPCS","0338-9640-12","NDC","facility","inpatient","5.394736","ML","JZ","29.25","29.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN 20 UNIT/ML IJ SOLN (IO)","81000008","CDM","0250","RC","J2598","HCPCS","42023-164-25","NDC","facility","inpatient","0.050000","ML","JZ","24.25","24.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN 0.2 UNIT/ML IV SOLN","81000008","CDM","0250","RC","J2598","HCPCS","42023-237-10","NDC","facility","inpatient","5.233614","ML","JZ","63.72","63.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN 20 UNIT/ML IV SOLN","81000008","CDM","0250","RC","J2598","HCPCS","55150-370-01","NDC","facility","inpatient","0.061764","ML","JZ","28.10","28.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROCAINAMIDE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2690","HCPCS","0409-1902-01","NDC","facility","inpatient","10.000000","ML",,"718.12","718.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCAINAMIDE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2690","HCPCS","0409-1902-11","NDC","facility","inpatient","10.000000","ML",,"718.06","718.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCAINAMIDE HCL 500 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2690","HCPCS","14789-900-02","NDC","facility","inpatient","2.000000","ML",,"2880","2880",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCAINAMIDE HCL 500 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2690","HCPCS","14789-900-07","NDC","facility","inpatient","1.928571","ML",,"2700","2700",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","0069-0234-01","NDC","facility","inpatient","1.000000","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","0409-4699-24","NDC","facility","inpatient","1.018957","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 200 MG/20ML IV EMUL","81000008","CDM","0250","RC","J2704","HCPCS","0409-4699-30","NDC","facility","inpatient","1.092861","ML","JZ","4.19","4.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","0409-4699-33","NDC","facility","inpatient","1.000000","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","16714-690-01","NDC","facility","inpatient","3.666666","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","16714-977-01","NDC","facility","inpatient","1.000000","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","25021-608-50","NDC","facility","inpatient","1.027081","ML","JZ","2.75","2.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","25021-608-51","NDC","facility","inpatient","1.046511","ML","JZ","2.25","2.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","43598-549-10","NDC","facility","inpatient","1.000000","ML","JZ","2.18","2.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","63323-269-29","NDC","facility","inpatient","1.000000","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","63323-269-50","NDC","facility","inpatient","1.059196","ML","JZ","2.51","2.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","63323-269-65","NDC","facility","inpatient","1.098485","ML","JZ","2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 200 MG/20ML IV EMUL","81000008","CDM","0250","RC","J2704","HCPCS","0409-4699-30","NDC","facility","inpatient","1.000000","ML","JZ,RISK","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","0409-4699-24","NDC","facility","inpatient","1.000000","ML",,"1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 200 MG/20ML IV EMUL","81000008","CDM","0250","RC","J2704","HCPCS","0409-4699-30","NDC","facility","inpatient","0.954545","ML",,"6.82","6.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10 MG/ML INJ (PEDIATRIC) SH","81000008","CDM","0250","RC","J2704","HCPCS","25021-608-20","NDC","facility","inpatient","1.222222","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","25021-608-50","NDC","facility","inpatient","1.198660","ML",,"2.54","2.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","25021-608-51","NDC","facility","inpatient","1.000000","ML",,"2.28","2.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","63323-269-29","NDC","facility","inpatient","1.046336","ML",,"34.5","34.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","63323-269-65","NDC","facility","inpatient","1.069651","ML",,"2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0250","RC","J2704","HCPCS","63323-269-50","NDC","facility","inpatient","1.000000","ML",,"2.52","2.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN","81000008","CDM","0250","RC","J2710","HCPCS","0641-6149-01","NDC","facility","inpatient","0.842857","ML",,"23.57","23.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN","81000008","CDM","0250","RC","J2710","HCPCS","76014-003-10","NDC","facility","inpatient","0.500000","ML",,"12.34","12.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROTAMINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2720","HCPCS","63323-229-30","NDC","facility","inpatient","1.006084","ML",,"15.29","15.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROTAMINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2720","HCPCS","63323-229-05","NDC","facility","inpatient","1.154929","ML",,"27.41","27.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROTAMINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2720","HCPCS","63323-229-30","NDC","facility","inpatient","1.157979","ML","JZ","15.45","15.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROTAMINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0250","RC","J2720","HCPCS","63323-229-05","NDC","facility","inpatient","1.019360","ML","JZ","21.85","21.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENTOLAMINE MESYLATE 5 MG IJ SOLR","81000008","CDM","0250","RC","J2760","HCPCS","0143-9564-01","NDC","facility","inpatient","11.666666","ME",,"2500","2500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENTOLAMINE MESYLATE 5 MG IJ SOLR","81000008","CDM","0250","RC","J2760","HCPCS","68094-101-20","NDC","facility","inpatient","5.000000","UN",,"2500","2500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2765","HCPCS","0409-3414-01","NDC","facility","inpatient","2.090537","ML","JZ","69.25","69.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2765","HCPCS","0703-4502-04","NDC","facility","inpatient","1.655949","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2765","HCPCS","23155-240-41","NDC","facility","inpatient","1.423188","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2765","HCPCS","0409-3414-01","NDC","facility","inpatient","2.000000","ML","JZ,RISK","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J2765","HCPCS","0409-3414-01","NDC","facility","inpatient","7.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RASBURICASE 1.5 MG/ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J2783","HCPCS","0024-5150-10","NDC","facility","inpatient","0.333333","UN","JZ","1562.93","1562.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"REGADENOSON 0.4 MG/5ML IV SOLN","81000008","CDM","0250","RC","J2785","HCPCS","0469-6501-89","NDC","facility","inpatient","2.916666","ML",,"329.46","329.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"REGADENOSON 0.4 MG/5ML IV SOLN","81000008","CDM","0250","RC","J2785","HCPCS","71288-201-85","NDC","facility","inpatient","1.284722","ML",,"42","42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY","81000008","CDM","0250","RC","J2790","HCPCS","13533-631-02","NDC","facility","inpatient","1.000000","UN",,"646.1","646.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY","81000008","CDM","0250","RC","J2790","HCPCS","0562-7805-01","NDC","facility","inpatient","1.306666","UN",,"819.91","819.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RHO D IMMUNE GLOBULIN 2500 UNIT/2.2ML IJ SOLN","81000008","CDM","0250","RC","J2792","HCPCS","70257-350-02","NDC","facility","inpatient","0.088000","ML","JZ","173.82","173.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ROMIPLOSTIM 250 MCG SC SOLR","81000008","CDM","0250","RC","J2796","HCPCS","55513-221-01","NDC","facility","inpatient","0.060465","UN","JZ","269.63","269.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ROMIPLOSTIM 125 MCG SC SOLR","81000008","CDM","0250","RC","J2796","HCPCS","55513-223-01","NDC","facility","inpatient","0.078814","UN","JZ","431.01","431.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SINCALIDE 5 MCG IJ SOLR","81000008","CDM","0250","RC","J2805","HCPCS","0270-0556-15","NDC","facility","inpatient","0.224000","UN","JZ","227.95","227.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SINCALIDE 5 MCG IJ SOLR","81000008","CDM","0250","RC","J2805","HCPCS","72266-248-01","NDC","facility","inpatient","0.326000","UN","JZ","347.42","347.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN","81000008","CDM","0250","RC","J2916","HCPCS","0024-2792-10","NDC","facility","inpatient","1.000000","ML","JZ","49.00","49.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN","81000008","CDM","0250","RC","J2916","HCPCS","0143-9570-10","NDC","facility","inpatient","1.050088","ML","JZ","48.82","48.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN","81000008","CDM","0250","RC","J2916","HCPCS","0024-2792-10","NDC","facility","inpatient","1.000000","ML",,"49.61","49.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN","81000008","CDM","0250","RC","J2916","HCPCS","0143-9298-10","NDC","facility","inpatient","1.000000","ML",,"12.86","12.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 500 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0003-02","NDC","facility","inpatient","5.000000","ME",,"3.70","3.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0018-20","NDC","facility","inpatient","0.005936","UN",,"2.69","2.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0047-22","NDC","facility","inpatient","5.000000","ME",,"3.50","3.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0698-01","NDC","facility","inpatient","48.260290","ME",,"0.83","0.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0758-01","NDC","facility","inpatient","0.010000","UN",,"2.04","2.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0047-22","NDC","facility","inpatient","0.041864","UN","JZ","4.14","4.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0039-28","NDC","facility","inpatient","0.121780","UN","JZ","15.33","15.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 500 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0003-02","NDC","facility","inpatient","5.000000","ME","JZ","3.70","3.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0250","RC","J2919","HCPCS","0009-0018-20","NDC","facility","inpatient","0.005000","UN","JZ","2.69","2.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","81000008","CDM","0250","RC","J2920","HCPCS","0009-0039-28","NDC","facility","inpatient","0.651376","UN","JZ","69.64","69.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 500 MG IJ SOLR","81000008","CDM","0250","RC","J2930","HCPCS","0009-0003-02","NDC","facility","inpatient","125.000000","ME","JZ","91.12","91.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0250","RC","J2930","HCPCS","0009-0018-20","NDC","facility","inpatient","0.117250","UN","JZ","65.59","65.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0250","RC","J2930","HCPCS","0009-0047-22","NDC","facility","inpatient","0.765453","UN","JZ","75.52","75.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 1000 MG IJ SOLR","81000008","CDM","0250","RC","J2930","HCPCS","63323-265-30","NDC","facility","inpatient","0.121875","UN","JZ","32.53","32.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 500 MG IJ SOLR","81000008","CDM","0250","RC","J2930","HCPCS","0009-0003-02","NDC","facility","inpatient","125.000000","ME",,"92.40","92.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0250","RC","J2930","HCPCS","0009-0018-20","NDC","facility","inpatient","0.125000","UN",,"66.00","66.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0250","RC","J2930","HCPCS","0009-0047-22","NDC","facility","inpatient","0.792631","UN",,"68.75","68.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0250","RC","J2930","HCPCS","0009-0698-01","NDC","facility","inpatient","616.617502","ME",,"10.17","10.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALTEPLASE 2 MG/2ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J2997","HCPCS","50242-041-10","NDC","facility","inpatient","0.500000","UN","JZ","423.22","423.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALTEPLASE 2 MG IJ SOLR","81000008","CDM","0250","RC","J2997","HCPCS","50242-041-64","NDC","facility","inpatient","0.558105","UN","JZ","502.88","502.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALTEPLASE 50 MG IV SOLR","81000008","CDM","0250","RC","J2997","HCPCS","50242-044-13","NDC","facility","inpatient","0.020000","UN","JZ","422.42","422.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALTEPLASE 100 MG IV SOLR","81000008","CDM","0250","RC","J2997","HCPCS","50242-085-27","NDC","facility","inpatient","0.010000","UN","JZ","171.73","171.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN","81000008","CDM","0250","RC","J3010","HCPCS","0409-9094-25","NDC","facility","inpatient","0.500000","ML","RISK","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"FENTANYL PF 10MCG/ML IN 0.9% NACL 10ML IV DRIP (PEDIATRIC) (PREMIX) SH","81000008","CDM","0250","RC","J3010","HCPCS","99999-0017-82","NDC","facility","inpatient","10.000000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 10MCG/ML IN 0.9% NACL INJ SOLN (PEDIATRIC) SH","81000008","CDM","0250","RC","J3010","HCPCS","70092-1400-43","NDC","facility","inpatient","0.116830","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 1500MCG/30ML NS IV DRIP (PREMIX) SH","81000008","CDM","0250","RC","J3010","HCPCS","70092-1180-79","NDC","facility","inpatient","2.121212","ML",,"12.16","12.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","81000008","CDM","0250","RC","J3010","HCPCS","0409-9094-22","NDC","facility","inpatient","0.993675","ML",,"89.75","89.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN","81000008","CDM","0250","RC","J3010","HCPCS","0409-9094-25","NDC","facility","inpatient","1.956781","ML",,"52.25","52.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE (PF) 1000 MCG/20ML IJ SOLN","81000008","CDM","0250","RC","J3010","HCPCS","0409-9094-31","NDC","facility","inpatient","4.666666","ML",,"9","9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE (PF) 2500 MCG/50ML IJ SOLN","81000008","CDM","0250","RC","J3010","HCPCS","0409-9094-61","NDC","facility","inpatient","2.000000","ML",,"5.22","5.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE 50MCG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3010","HCPCS","0641-6027-25","NDC","facility","inpatient","1.075366","ML",,"89.68","89.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE (PF) 2500 MCG/50ML IJ SOLN","81000008","CDM","0250","RC","J3010","HCPCS","0641-6030-01","NDC","facility","inpatient","2.000000","ML",,"6","6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE 50MCG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3010","HCPCS","63323-806-02","NDC","facility","inpatient","0.901093","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE (PF) 1000 MCG/20ML IJ SOLN","81000008","CDM","0250","RC","J3010","HCPCS","63323-806-14","NDC","facility","inpatient","3.568627","ML",,"5.81","5.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE (PF) 2500 MCG/50ML IJ SOLN","81000008","CDM","0250","RC","J3010","HCPCS","63323-806-50","NDC","facility","inpatient","2.000000","ML",,"6","6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 2500MCG/250ML NS IV DRIP (PREMIX) SH","81000008","CDM","0250","RC","J3010","HCPCS","70092-1093-37","NDC","facility","inpatient","10.488656","ML",,"7.82","7.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 2MCG/ML, BUPIVACAINE PF 0.1% IN NS 250ML PCEA (PREMIX)","81000008","CDM","0250","RC","J3010","HCPCS","70092-1160-37","NDC","facility","inpatient","57.360805","ML",,"47.02","47.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TENECTEPLASE 50MG/10ML INJ (FOR STROKE) SH","81000008","CDM","0250","RC","J3101","HCPCS","50242-120-47","NDC","facility","inpatient","0.021401","UN","JZ","462.95","462.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TERBUTALINE SULFATE 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3105","HCPCS","63323-665-01","NDC","facility","inpatient","0.338181","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TERBUTALINE SULFATE 1 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3105","HCPCS","0143-9746-10","NDC","facility","inpatient","0.285087","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CHLORPROMAZINE HCL 25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3230","HCPCS","0641-1397-35","NDC","facility","inpatient","1.500000","ML",,"225.36","225.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLORPROMAZINE HCL 50 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J3230","HCPCS","0641-1398-35","NDC","facility","inpatient","0.466666","ML",,"96.34","96.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN SULFATE 40 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3260","HCPCS","67457-473-22","NDC","facility","inpatient","2.828125","ML",,"56.25","56.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN","81000008","CDM","0250","RC","J3260","HCPCS","67457-428-30","NDC","facility","inpatient","1.672142","ML",,"20.66","20.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN SULFATE 40 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3260","HCPCS","63323-306-30","NDC","facility","inpatient","1.844750","ML",,"22.94","22.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN SULFATE 1.2 G IJ SOLR","81000008","CDM","0250","RC","J3260","HCPCS","63323-303-51","NDC","facility","inpatient","80.000000","ME",,"43.42","43.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN SULFATE 40 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3260","HCPCS","0409-3578-01","NDC","facility","inpatient","1.966666","ML",,"25.04","25.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP","81000008","CDM","0250","RC","J3301","HCPCS","0003-0293-05","NDC","facility","inpatient","0.367647","ML","JZ","20.77","20.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP","81000008","CDM","0250","RC","J3301","HCPCS","70121-1049-5","NDC","facility","inpatient","0.308823","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRIPTORELIN PAMOATE 3.75 MG IM SUSR","81000008","CDM","0250","RC","J3316","HCPCS","74676-5902-1","NDC","facility","inpatient","1.000000","UN","JZ","5200","5200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIAZEPAM 5 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3360","HCPCS","0409-1273-32","NDC","facility","inpatient","0.913662","ML",,"99.68","99.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1250MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","0143-9152-01","NDC","facility","inpatient","0.333333","UN",,"56.28","56.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 5 MG/ML IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0250","RC","J3370","HCPCS","0338-3552-48","NDC","facility","inpatient","15.423333","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL IN DEXTROSE 750-5 MG/150ML-% IV SOLN","81000008","CDM","0250","RC","J3370","HCPCS","0338-3580-48","NDC","facility","inpatient","75.233935","ML",,"51.40","51.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1500MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","0409-3515-01","NDC","facility","inpatient","0.388295","UN",,"67.81","67.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 500 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J3370","HCPCS","0409-4332-01","NDC","facility","inpatient","1.060649","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 5 G IV SOLR","81000008","CDM","0250","RC","J3370","HCPCS","0409-6509-01","NDC","facility","inpatient","0.034444","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","0409-6533-01","NDC","facility","inpatient","125.000000","ML",,"67.37","67.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","0409-6533-21","NDC","facility","inpatient","0.516348","UN",,"68.39","68.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","16714-309-01","NDC","facility","inpatient","0.500000","UN",,"67.37","67.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","25021-151-20","NDC","facility","inpatient","0.500000","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1250MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","55150-471-01","NDC","facility","inpatient","0.358082","UN",,"56.32","56.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL IN NACL 1.25-0.9 GM/250ML-% IV SOLN","81000008","CDM","0250","RC","J3370","HCPCS","70092-9054-05","NDC","facility","inpatient","83.333333","ML",,"61.83","61.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 33MG/ML FORTIFIED OPHTH SOLN *COMPOUNDED* SH","81000008","CDM","0250","RC","J3370","HCPCS","99999-0015-92","NDC","facility","inpatient","39.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 25MG/ML BSS OPHTH SOLN *COMPOUND* SH","81000008","CDM","0250","RC","J3370","HCPCS","99999-0019-63","NDC","facility","inpatient","0.057792","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 1 G IV SOLR","81000008","CDM","0250","RC","J3370","HCPCS","67457-340-01","NDC","facility","inpatient","0.517857","UN",,"64.46","64.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 5 MG/ML IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0250","RC","J3370","HCPCS","0338-3552-48","NDC","facility","inpatient","106.080000","ML","JZ","105.3","105.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 500 MG/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J3370","HCPCS","0409-4332-01","NDC","facility","inpatient","0.752294","UN","JZ","71.83","71.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 750MG/250ML NS (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","0409-6531-02","NDC","facility","inpatient","0.527101","UN","JZ","41.33","41.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","0409-6533-01","NDC","facility","inpatient","536.748676","ME","JZ","62.61","62.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","0409-6533-21","NDC","facility","inpatient","0.505729","UN","JZ","57.36","57.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","16714-309-01","NDC","facility","inpatient","0.470370","UN","JZ","59.16","59.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3370","HCPCS","25021-151-20","NDC","facility","inpatient","0.450000","UN","JZ","39.04","39.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN HCL 1 G IV SOLR","81000008","CDM","0250","RC","J3371","HCPCS","67457-340-01","NDC","facility","inpatient","0.578260","UN","JZ","63.8","63.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN HCL 1 G IV SOLR","81000008","CDM","0250","RC","J3371","HCPCS","67457-340-01","NDC","facility","inpatient","0.538461","UN",,"67.38","67.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1250MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3371","HCPCS","67457-823-99","NDC","facility","inpatient","0.351864","UN",,"56.27","56.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1500MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0250","RC","J3371","HCPCS","67457-824-99","NDC","facility","inpatient","0.333333","UN",,"67.54","67.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 25 MG/ML IM SOLN","81000008","CDM","0250","RC","J3410","HCPCS","0517-4201-25","NDC","facility","inpatient","0.941935","ML",,"207.57","207.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXYZINE HCL 50 MG/ML IM SOLN","81000008","CDM","0250","RC","J3410","HCPCS","0517-5601-25","NDC","facility","inpatient","0.569767","ML",,"118.64","118.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3411","HCPCS","0641-6228-25","NDC","facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3411","HCPCS","25021-500-02","NDC","facility","inpatient","1.007496","ML",,"48.71","48.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3411","HCPCS","43598-050-11","NDC","facility","inpatient","1.000000","ML",,"33.09","33.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3411","HCPCS","43598-050-25","NDC","facility","inpatient","1.074267","ML",,"41.99","41.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3411","HCPCS","63323-013-02","NDC","facility","inpatient","1.043839","ML",,"49.82","49.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3411","HCPCS","67457-196-02","NDC","facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3411","HCPCS","70748-347-01","NDC","facility","inpatient","1.000000","ML",,"67.19","67.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3411","HCPCS","72603-139-01","NDC","facility","inpatient","1.000000","ML",,"63.18","63.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J3420","HCPCS","0143-9621-25","NDC","facility","inpatient","1.127118","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J3420","HCPCS","16729-533-63","NDC","facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J3420","HCPCS","63323-044-00","NDC","facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J3420","HCPCS","70069-005-10","NDC","facility","inpatient","1.200000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J3420","HCPCS","70710-1663-1","NDC","facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0250","RC","J3420","HCPCS","71288-303-01","NDC","facility","inpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXOCOBALAMIN 5 G IV SOLR","81000008","CDM","0250","RC","J3424","HCPCS","50633-310-11","NDC","facility","inpatient","0.009444","UN",,"23.36","23.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXOCOBALAMIN 5 G IV SOLR","81000008","CDM","0250","RC","J3424","HCPCS","11704-370-01","NDC","facility","inpatient","0.005000","UN",,"19.71","19.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHYTONADIONE 1 MG/0.5ML IJ SOLN","81000008","CDM","0250","RC","J3430","HCPCS","76329-1240-1","NDC","facility","inpatient","0.543061","ML","JZ","206.66","206.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHYTONADIONE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3430","HCPCS","0409-9158-01","NDC","facility","inpatient","0.105156","ML",,"38.23","38.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHYTONADIONE 10 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3430","HCPCS","43598-405-11","NDC","facility","inpatient","0.100000","ML",,"33.36","33.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHYTONADIONE 1 MG/0.5ML IJ SOLN","81000008","CDM","0250","RC","J3430","HCPCS","76329-1240-1","NDC","facility","inpatient","17.250000","ML",,"202.62","202.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J3465","HCPCS","0049-3190-28","NDC","facility","inpatient","0.050000","UN","JZ","23.06","23.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VORICONAZOLE 200 MG IV SOLR","81000008","CDM","0250","RC","J3465","HCPCS","0781-3416-94","NDC","facility","inpatient","0.050000","UN","JZ","48.75","48.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J3465","HCPCS","70436-029-80","NDC","facility","inpatient","0.050621","UN","JZ","41.61","41.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J3465","HCPCS","71288-027-30","NDC","facility","inpatient","0.050000","UN","JZ","13.67","13.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYALURONIDASE OVINE 200 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J3471","HCPCS","24208-002-02","NDC","facility","inpatient","0.005000","ML","JZ","4.2","4.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","J3473","HCPCS","18657-117-04","NDC","facility","inpatient","0.006666","ML","JZ","3.11","3.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","67457-567-00","NDC","facility","inpatient","54.285714","ML",,"37.17","37.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 4G/100ML SW IV DRIP (PREMIX) SH","81000008","CDM","0250","RC","J3475","HCPCS","0264-4206-54","NDC","facility","inpatient","15.097402","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","0264-4400-54","NDC","facility","inpatient","52.739726","ML",,"36.97","36.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","0338-1708-40","NDC","facility","inpatient","12.500000","ML",,"26.42","26.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","0338-1709-40","NDC","facility","inpatient","53.760229","ML",,"37.36","37.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 4G/100ML SW IV DRIP (PREMIX) SH","81000008","CDM","0250","RC","J3475","HCPCS","0338-1715-40","NDC","facility","inpatient","16.421568","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","0409-6727-23","NDC","facility","inpatient","50.000000","ML",,"37.19","37.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 20G/500ML STERILE WATER (PREMIX) SH","81000008","CDM","0250","RC","J3475","HCPCS","0409-6729-03","NDC","facility","inpatient","12.500000","ML",,"1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","0409-6729-11","NDC","facility","inpatient","13.425925","ML",,"34.04","34.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 4 GM/100ML IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","0409-6729-23","NDC","facility","inpatient","17.500000","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","0409-6729-24","NDC","facility","inpatient","13.430232","ML",,"32.35","32.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 2-5 GM/50ML-% IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","0517-2602-25","NDC","facility","inpatient","12.500000","ML",,"59.77","59.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","25021-612-81","NDC","facility","inpatient","12.951467","ML",,"35.18","35.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","44567-420-24","NDC","facility","inpatient","12.500000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 4G/100ML SW IV DRIP (PREMIX) SH","81000008","CDM","0250","RC","J3475","HCPCS","44567-421-24","NDC","facility","inpatient","13.815789","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","47335-992-01","NDC","facility","inpatient","12.500000","ML",,"27.56","27.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 50 % IJ SOLN","81000008","CDM","0250","RC","J3475","HCPCS","63323-064-03","NDC","facility","inpatient","1.316491","ML",,"28.12","28.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 4G/100ML SW IV DRIP (PREMIX) SH","81000008","CDM","0250","RC","J3475","HCPCS","63323-106-01","NDC","facility","inpatient","14.005326","ML",,"9.37","9.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","63323-106-05","NDC","facility","inpatient","13.327980","ML",,"29.22","29.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0250","RC","J3475","HCPCS","63323-108-01","NDC","facility","inpatient","52.072538","ML",,"37.42","37.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","0409-6635-01","NDC","facility","inpatient","1.173913","ML","JZ","13.18","13.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","0409-6653-05","NDC","facility","inpatient","1.144010","ML","JZ","4.65","4.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","0409-7074-26","NDC","facility","inpatient","20.000000","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","63323-965-01","NDC","facility","inpatient","1.428571","ML","JZ","12.97","12.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","63323-965-02","NDC","facility","inpatient","1.015950","ML","JZ","10.24","10.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","63323-965-03","NDC","facility","inpatient","1.000000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","63323-965-10","NDC","facility","inpatient","1.098981","ML","JZ","8.54","8.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","63323-965-20","NDC","facility","inpatient","1.000000","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"D5W - NACL 0.45% WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0264-7635-00","NDC","facility","inpatient","100.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.9% WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0264-7652-00","NDC","facility","inpatient","100.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% WITH KCL 10 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0338-0669-04","NDC","facility","inpatient","200.000000","ML",,"16.8","16.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0338-0671-04","NDC","facility","inpatient","107.197917","ML",,"7.49","7.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% WITH KCL 40 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0338-0675-04","NDC","facility","inpatient","50.000000","ML",,"4.2","4.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% WITH KCL 20 MEQ 1000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0338-0691-04","NDC","facility","inpatient","119.753086","ML",,"8.64","8.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.45% WITH KCL 20 MEQ 1000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0338-0704-34","NDC","facility","inpatient","147.033730","ML",,"8.17","8.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","0338-0705-48","NDC","facility","inpatient","10.405100","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","0338-0709-48","NDC","facility","inpatient","21.744733","ML",,"14.95","14.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.9% WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0338-0803-04","NDC","facility","inpatient","113.247863","ML",,"8.22","8.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0338-0811-04","NDC","facility","inpatient","108.000000","ML",,"9.1","9.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","0409-7075-26","NDC","facility","inpatient","10.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0409-7902-09","NDC","facility","inpatient","100.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","0990-7074-26","NDC","facility","inpatient","22.430379","ML",,"14.99","14.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","0990-7075-26","NDC","facility","inpatient","11.411764","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0990-7111-09","NDC","facility","inpatient","109.523809","ML",,"7.7","7.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% WITH KCL 40 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","0990-7904-09","NDC","facility","inpatient","50.000000","ML",,"3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0250","RC","J3480","HCPCS","14789-136-07","NDC","facility","inpatient","1.000000","ML",,"13.44","13.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% WITH KCL 20 MEQ 1000 ML","81000008","CDM","0250","RC","J3480","HCPCS","63323-686-01","NDC","facility","inpatient","100.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% WITH KCL 10 MEQ 1,000 ML","81000008","CDM","0250","RC","J3480","HCPCS","65219-142-02","NDC","facility","inpatient","200.000000","ML",,"15.4","15.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZIPRASIDONE MESYLATE 20 MG IM SOLR","81000008","CDM","0250","RC","J3486","HCPCS","43598-848-58","NDC","facility","inpatient","1.071428","UN",,"186.12","186.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZOLEDRONIC ACID 4 MG/100ML IV SOLN","81000008","CDM","0250","RC","J3489","HCPCS","25021-826-82","NDC","facility","inpatient","23.891129","ML",,"266.89","266.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZOLEDRONIC ACID 4 MG/5ML IV CONC","81000008","CDM","0250","RC","J3489","HCPCS","55111-685-07","NDC","facility","inpatient","1.083333","ML","JZ","128.97","128.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000008","CDM","0250","RC","J3490","HCPCS","81284-611-00","NDC","facility","inpatient","10.148659","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000008","CDM","0250","RC","J3490","HCPCS","81284-611-10","NDC","facility","inpatient","10.357142","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J3490","HCPCS","72485-417-01","NDC","facility","inpatient","0.405000","UN","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J3490","HCPCS","71288-032-20","NDC","facility","inpatient","1.591000","UN","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","70860-784-05","NDC","facility","inpatient","3.391304","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0143-9785-10","NDC","facility","inpatient","3.320833","ML","JZ","99.95","99.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0409-0152-24","NDC","facility","inpatient","100.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0409-3613-01","NDC","facility","inpatient","0.750000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0409-7811-24","NDC","facility","inpatient","100.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ISAVUCONAZONIUM SULFATE 372 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J3490","HCPCS","0469-0420-01","NDC","facility","inpatient","0.002688","UN","JZ","6.18","6.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0517-4601-25","NDC","facility","inpatient","0.826530","ML","JZ","113.75","113.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DILTIAZEM HCL 25 MG/5ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0641-6013-10","NDC","facility","inpatient","2.686309","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DILTIAZEM HCL 50 MG/10ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0641-6014-10","NDC","facility","inpatient","3.625000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","0641-6022-25","NDC","facility","inpatient","2.872159","ML","JZ","73.91","73.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J3490","HCPCS","0641-6117-10","NDC","facility","inpatient","0.220382","UN","JZ","57","57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","70860-784-41","NDC","facility","inpatient","3.583333","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DILTIAZEM HCL 25 MG/5ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0641-9217-10","NDC","facility","inpatient","1.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN 0.2 UNIT/ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","42023-237-10","NDC","facility","inpatient","100.000000","ML","JZ","1274.5","1274.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3490","HCPCS","43547-543-01","NDC","facility","inpatient","0.908333","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0250","RC","J3490","HCPCS","55150-117-20","NDC","facility","inpatient","0.284072","UN","JZ","54.19","54.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0250","RC","J3490","HCPCS","55150-172-30","NDC","facility","inpatient","20.830000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","63323-494-01","NDC","facility","inpatient","5.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","63323-494-05","NDC","facility","inpatient","4.818181","ML","JZ","57.15","57.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR","81000008","CDM","0250","RC","J3490","HCPCS","63323-649-07","NDC","facility","inpatient","1.000000","UN","JZ","633.5","633.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","63323-739-12","NDC","facility","inpatient","1.251711","ML","JZ","39.88","39.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","67457-433-22","NDC","facility","inpatient","1.110000","ML","JZ","56.25","56.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NOREPINEPHRINE 8MG/250ML D5W SH (NON-WT BASED DOSING)","81000008","CDM","0250","RC","J3490","HCPCS","70092-9036-17","NDC","facility","inpatient","67.501331","ML","JZ","104.99","104.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000008","CDM","0250","RC","J3490","HCPCS","39822-1000-1","NDC","facility","inpatient","13.789213","ML","JZ","56.02","56.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","0641-6022-25","NDC","facility","inpatient","2.000000","ML","JZ,RISK","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier RISK: Modifier description not available"
"NOREPINEPHRINE 8MG/250ML NS SH (NON-WT BASED DOSING)","81000008","CDM","0250","RC","J3490","HCPCS","70092-1651-05","NDC","facility","inpatient","291.666666","ML",,"272.02","272.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NOREPINEPHRINE 8MG/250ML NS SH (NON-WT BASED DOSING)","81000008","CDM","0250","RC","J3490","HCPCS","71266-5015-2","NDC","facility","inpatient","296.571798","ML",,"329.86","329.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","80830-2329-1","NDC","facility","inpatient","100.000000","ML",,"172.2","172.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NOREPINEPHRINE 8MG/250ML NS SH (NON-WT BASED DOSING)","81000008","CDM","0250","RC","J3490","HCPCS","99999-0026-76","NDC","facility","inpatient","250.000000","ML",,"1725","1725",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","70092-1575-36","NDC","facility","inpatient","175.000000","ML",,"184.71","184.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","0409-9558-10","NDC","facility","inpatient","6.000000","ML","RISK","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"NOREPINEPHRINE 8MG/250ML NS SH (NON-WT BASED DOSING)","81000008","CDM","0250","RC","J3490","HCPCS","70092-1035-05","NDC","facility","inpatient","259.090909","ML",,"316.04","316.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","70092-1007-36","NDC","facility","inpatient","125.000000","ML",,"282.75","282.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","67457-852-04","NDC","facility","inpatient","4.469473","ML",,"137.54","137.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","0052-0450-10","NDC","facility","inpatient","8.500000","ML",,"269.56","269.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 2.5 MG PO TABS","81000008","CDM","0250","RC","J3490","HCPCS","0054-8740-25","NDC","facility","inpatient","0.348717","UN",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR","81000008","CDM","0250","RC","J3490","HCPCS","0206-8852-16","NDC","facility","inpatient","0.333333","UN",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 100MCG/ML INJ","81000008","CDM","0250","RC","J3490","HCPCS","0338-1047-02","NDC","facility","inpatient","1.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","0409-2339-34","NDC","facility","inpatient","4.500000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","0409-3189-05","NDC","facility","inpatient","6.708260","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","0409-9558-05","NDC","facility","inpatient","6.681034","ML",,"65.52","65.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","0409-9558-10","NDC","facility","inpatient","9.014843","ML",,"64.97","64.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL 25 MG/5ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","0641-6013-10","NDC","facility","inpatient","20.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 2.25 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J3490","HCPCS","0781-3110-95","NDC","facility","inpatient","0.833333","UN",,"43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXOCOBALAMIN 5 G IV SOLR","81000008","CDM","0250","RC","J3490","HCPCS","11704-370-01","NDC","facility","inpatient","1.000000","UN",,"3942.32","3942.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000008","CDM","0250","RC","J3490","HCPCS","39822-1000-1","NDC","facility","inpatient","10.000000","ML",,"52.55","52.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","39822-4200-2","NDC","facility","inpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VASOPRESSIN 0.2 UNIT/ML IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","42023-237-10","NDC","facility","inpatient","1.016460","ML",,"61.27","61.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","43066-007-10","NDC","facility","inpatient","8.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NOREPINEPHRINE 8MG/250ML NS SH (NON-WT BASED DOSING)","81000008","CDM","0250","RC","J3490","HCPCS","44567-641-01","NDC","facility","inpatient","583.333333","ML",,"381.88","381.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROXOCOBALAMIN 5 G IV SOLR","81000008","CDM","0250","RC","J3490","HCPCS","50633-310-11","NDC","facility","inpatient","0.953846","UN",,"4472.31","4472.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN","81000008","CDM","0250","RC","J3490","HCPCS","51754-0108-1","NDC","facility","inpatient","111.812500","ML",,"174.91","174.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","55150-225-05","NDC","facility","inpatient","5.555555","ML",,"76.32","76.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 50 MG/5ML IV SOSY","81000008","CDM","0250","RC","J3490","HCPCS","63037-155-25","NDC","facility","inpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J3490","HCPCS","63323-426-05","NDC","facility","inpatient","5.833333","ML",,"87.94","87.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0250","RC","J3490","HCPCS","64679-012-01","NDC","facility","inpatient","0.200000","UN",,"38.57","38.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 50 MG/5ML IV SOSY","81000008","CDM","0250","RC","J3490","HCPCS","66647-6010-25","NDC","facility","inpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3590","HCPCS","72205-101-01","NDC","facility","inpatient","1.000000","ML",,"13.39","13.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3590","HCPCS","65219-572-10","NDC","facility","inpatient","1.000000","ML",,"2.89","2.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3590","HCPCS","65219-572-01","NDC","facility","inpatient","1.000000","ML",,"6.25","6.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3590","HCPCS","0641-6007-10","NDC","facility","inpatient","1.000000","ML",,"2.89","2.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0250","RC","J3590","HCPCS","0641-6008-10","NDC","facility","inpatient","1.000000","ML",,"12.60","12.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT","81000008","CDM","0250","RC","J7168","HCPCS","63833-387-02","NDC","facility","inpatient","0.568894","UN","JZ","8.20","8.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT","81000008","CDM","0250","RC","J7168","HCPCS","63833-386-02","NDC","facility","inpatient","2.000000","UN",,"8.31","8.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT","81000008","CDM","0250","RC","J7168","HCPCS","63833-386-02","NDC","facility","inpatient","0.627575","UN","JZ","8.31","8.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADAMTS13 RECOMBINANT-KRHN 500 UNITS IV KIT","81000008","CDM","0250","RC","J7171","HCPCS","64764-140-05","NDC","facility","inpatient","0.019962","UN","JZ","117.98","117.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADAMTS13 RECOMBINANT-KRHN 1500 UNITS IV KIT","81000008","CDM","0250","RC","J7171","HCPCS","64764-145-05","NDC","facility","inpatient","0.006651","UN","JZ","117.93","117.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR","81000008","CDM","0250","RC","J7197","HCPCS","13533-603-20","NDC","facility","inpatient","1.000000","UN",,"15.6","15.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVONORGESTREL 19.5 MG IU IUD","81000008","CDM","0250","RC","J7296","HCPCS","50419-424-01","NDC","facility","inpatient","1.000000","UN",,"5552.6","5552.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVONORGESTREL 20.1 MCG/DAY IU IUD","81000008","CDM","0250","RC","J7297","HCPCS","0023-5858-01","NDC","facility","inpatient","1.000000","UN",,"4259.32","4259.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PARAGARD INTRAUTERINE COPPER IU IUD","81000008","CDM","0250","RC","J7300","HCPCS","51285-204-01","NDC","facility","inpatient","1.000000","UN",,"4245.6","4245.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETONOGESTREL 68 MG SC IMPL","81000008","CDM","0250","RC","J7307","HCPCS","78206-145-01","NDC","facility","inpatient","1.000000","UN",,"5550.16","5550.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZATHIOPRINE 25MG PO PRE-SPLIT TABS SH","81000008","CDM","0250","RC","J7500","HCPCS","0054-8084-25","NDC","facility","inpatient","0.600000","UN",,"12.27","12.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZATHIOPRINE 50 MG PO TABS","81000008","CDM","0250","RC","J7500","HCPCS","68084-229-01","NDC","facility","inpatient","1.011029","UN",,"12.66","12.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOSPORINE MODIFIED 100 MG PO CAPS","81000008","CDM","0250","RC","J7502","HCPCS","0074-3109-32","NDC","facility","inpatient","1.216216","UN",,"29.93","29.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOSPORINE MODIFIED 100 MG/ML PO SOLN","81000008","CDM","0250","RC","J7502","HCPCS","0074-7269-50","NDC","facility","inpatient","0.786458","ML",,"38.73","38.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS ER 0.75 MG PO TB24","81000008","CDM","0250","RC","J7503","HCPCS","68992-3075-3","NDC","facility","inpatient","0.333333","UN",,"8.95","8.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS ER 1 MG PO TB24","81000008","CDM","0250","RC","J7503","HCPCS","68992-3010-3","NDC","facility","inpatient","0.250000","UN",,"7.44","7.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS ER 4 MG PO TB24","81000008","CDM","0250","RC","J7503","HCPCS","68992-3040-3","NDC","facility","inpatient","0.062500","UN",,"6.11","6.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 5 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","0469-0657-11","NDC","facility","inpatient","0.200000","UN",,"21.72","21.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 0.5 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","0904-6623-61","NDC","facility","inpatient","1.022539","UN",,"14.90","14.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 5 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","0904-6624-61","NDC","facility","inpatient","0.199913","UN",,"10.98","10.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 1 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","0904-7097-61","NDC","facility","inpatient","1.016377","UN",,"10.39","10.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 5 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","16729-043-01","NDC","facility","inpatient","0.199328","UN",,"17.80","17.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 5 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","51079-028-20","NDC","facility","inpatient","0.200847","UN",,"17.06","17.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 0.5 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","51079-817-20","NDC","facility","inpatient","1.007812","UN",,"15.07","15.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 1 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","51079-818-20","NDC","facility","inpatient","1.008680","UN",,"22.19","22.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 1 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","0469-0617-73","NDC","facility","inpatient","1.000000","UN",,"36.83","36.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 1 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","0469-0617-11","NDC","facility","inpatient","1.000000","UN",,"31.42","31.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 0.5 MG PO CAPS","81000008","CDM","0250","RC","J7507","HCPCS","0469-0607-73","NDC","facility","inpatient","1.148148","UN",,"23.53","23.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 5 MG/ML PO CONC","81000008","CDM","0250","RC","J7510","HCPCS","0054-3721-44","NDC","facility","inpatient","1.104347","ML",,"25.06","25.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN","81000008","CDM","0250","RC","J7510","HCPCS","0121-0759-08","NDC","facility","inpatient","1.666662","ML",,"3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN","81000008","CDM","0250","RC","J7510","HCPCS","60432-212-08","NDC","facility","inpatient","1.631435","ML",,"3.41","3.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR","81000008","CDM","0250","RC","J7511","HCPCS","58468-0080-1","NDC","facility","inpatient","1.195115","UN","JZ","2991.63","2991.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0054-0017-20","NDC","facility","inpatient","0.105573","UN",,"1.44","1.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 20 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0054-0018-20","NDC","facility","inpatient","0.051982","UN",,"0.40","0.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 50 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0054-0019-20","NDC","facility","inpatient","0.021131","UN",,"0.18","0.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 5 MG/5ML PO SOLN","81000008","CDM","0250","RC","J7512","HCPCS","0054-3722-50","NDC","facility","inpatient","1.000000","ML",,"5.2","5.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 5 MG/5ML PO SOLN","81000008","CDM","0250","RC","J7512","HCPCS","0054-3722-63","NDC","facility","inpatient","0.803592","ML",,"3.66","3.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 5 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0054-8724-25","NDC","facility","inpatient","0.194824","UN",,"2.59","2.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 1 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0054-8739-25","NDC","facility","inpatient","1.023936","UN",,"5.86","5.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 2.5 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0054-8740-25","NDC","facility","inpatient","0.353703","UN",,"4.51","4.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0054-9817-25","NDC","facility","inpatient","0.100000","UN",,"1.59","1.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0378-0641-01","NDC","facility","inpatient","0.100000","UN",,"1.59","1.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0904-6923-61","NDC","facility","inpatient","0.102484","UN",,"1.48","1.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 20 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","0904-7127-61","NDC","facility","inpatient","0.051031","UN",,"0.39","0.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 1 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","59651-484-01","NDC","facility","inpatient","1.029707","UN",,"5.12","5.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 2.5 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","59651-485-01","NDC","facility","inpatient","0.359042","UN",,"3.90","3.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 50 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","59651-489-01","NDC","facility","inpatient","0.020369","UN",,"0.17","0.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 1 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","59746-171-06","NDC","facility","inpatient","0.990566","UN",,"5.83","5.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","59746-173-06","NDC","facility","inpatient","0.100582","UN",,"1.46","1.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 20 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","59746-175-06","NDC","facility","inpatient","0.052006","UN",,"0.47","0.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 5 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","60687-122-01","NDC","facility","inpatient","0.203914","UN",,"2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","60687-134-01","NDC","facility","inpatient","0.100672","UN",,"1.46","1.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 20 MG PO TABS","81000008","CDM","0250","RC","J7512","HCPCS","60687-145-01","NDC","facility","inpatient","0.056940","UN",,"0.38","0.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOSPORINE MODIFIED 25 MG PO CAPS","81000008","CDM","0250","RC","J7515","HCPCS","0074-3108-32","NDC","facility","inpatient","1.000000","UN",,"12.47","12.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOSPORINE 25 MG PO CAPS","81000008","CDM","0250","RC","J7515","HCPCS","0078-0240-15","NDC","facility","inpatient","1.000000","UN",,"27.60","27.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOSPORINE MODIFIED 25 MG PO CAPS","81000008","CDM","0250","RC","J7515","HCPCS","0093-9018-19","NDC","facility","inpatient","1.000000","UN",,"8.52","8.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 250 MG PO CAPS","81000008","CDM","0250","RC","J7517","HCPCS","0004-0259-01","NDC","facility","inpatient","1.000000","UN",,"37.29","37.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 500 MG PO TABS","81000008","CDM","0250","RC","J7517","HCPCS","0004-0260-01","NDC","facility","inpatient","0.500000","UN",,"35.76","35.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR","81000008","CDM","0250","RC","J7517","HCPCS","0004-0261-29","NDC","facility","inpatient","1.280017","ML",,"40.73","40.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 250 MG PO CAPS","81000008","CDM","0250","RC","J7517","HCPCS","0093-7334-01","NDC","facility","inpatient","1.000000","UN",,"16.53","16.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 250 MG PO CAPS","81000008","CDM","0250","RC","J7517","HCPCS","51079-721-20","NDC","facility","inpatient","1.004262","UN",,"17.66","17.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 250 MG PO CAPS","81000008","CDM","0250","RC","J7517","HCPCS","64380-726-06","NDC","facility","inpatient","1.000000","UN",,"17.03","17.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 500 MG PO TABS","81000008","CDM","0250","RC","J7517","HCPCS","60687-438-11","NDC","facility","inpatient","0.505390","UN",,"4.56","4.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE SODIUM 180 MG PO TBEC","81000008","CDM","0250","RC","J7518","HCPCS","0078-0385-66","NDC","facility","inpatient","1.000000","UN",,"44.79","44.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE SODIUM 360 MG PO TBEC","81000008","CDM","0250","RC","J7518","HCPCS","0078-0386-66","NDC","facility","inpatient","0.500000","UN",,"25.58","25.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE SODIUM 360 MG PO TBEC","81000008","CDM","0250","RC","J7518","HCPCS","0904-6786-61","NDC","facility","inpatient","0.520779","UN",,"24.70","24.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE SODIUM 180 MG PO TBEC","81000008","CDM","0250","RC","J7518","HCPCS","68084-907-21","NDC","facility","inpatient","1.040268","UN",,"27.28","27.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE SODIUM 360 MG PO TBEC","81000008","CDM","0250","RC","J7518","HCPCS","68084-918-25","NDC","facility","inpatient","0.505936","UN",,"22.37","22.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR","81000008","CDM","0250","RC","J7519","HCPCS","71288-803-21","NDC","facility","inpatient","0.020958","UN","JZ","9.75","9.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR","81000008","CDM","0250","RC","J7519","HCPCS","71288-803-20","NDC","facility","inpatient","0.020000","UN","JZ","9.83","9.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR","81000008","CDM","0250","RC","J7519","HCPCS","0004-0298-09","NDC","facility","inpatient","0.020000","UN","JZ","12.96","12.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SIROLIMUS 0.5 MG PO TABS","81000008","CDM","0250","RC","J7520","HCPCS","0008-1040-05","NDC","facility","inpatient","1.000000","UN",,"82.5","82.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIROLIMUS 1 MG PO TABS","81000008","CDM","0250","RC","J7520","HCPCS","16714-188-01","NDC","facility","inpatient","1.000000","UN",,"58.72","58.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIROLIMUS 1 MG PO TABS","81000008","CDM","0250","RC","J7520","HCPCS","50268-718-13","NDC","facility","inpatient","1.000000","UN",,"105.26","105.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIROLIMUS 0.5 MG PO TABS","81000008","CDM","0250","RC","J7520","HCPCS","59762-1001-1","NDC","facility","inpatient","1.083333","UN",,"48.38","48.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIROLIMUS 1 MG/ML PO SOLN","81000008","CDM","0250","RC","J7520","HCPCS","72205-099-78","NDC","facility","inpatient","1.000000","ML",,"157.9","157.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 5 MG/ML IV SOLN","81000008","CDM","0250","RC","J7525","HCPCS","0469-3016-01","NDC","facility","inpatient","0.167500","ML",,"119.59","119.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EVEROLIMUS 0.25 MG PO TABS","81000008","CDM","0250","RC","J7527","HCPCS","51991-379-06","NDC","facility","inpatient","1.000000","UN",,"65.07","65.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EVEROLIMUS 0.25 MG PO TABS","81000008","CDM","0250","RC","J7527","HCPCS","51991-379-60","NDC","facility","inpatient","1.000000","UN",,"65.04","65.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EVEROLIMUS 0.25 MG PO TABS","81000008","CDM","0250","RC","J7527","HCPCS","51991-379-99","NDC","facility","inpatient","1.000000","UN",,"65.07","65.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EVEROLIMUS 0.5 MG PO TABS","81000008","CDM","0250","RC","J7527","HCPCS","51991-380-60","NDC","facility","inpatient","0.530534","UN",,"65.07","65.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EVEROLIMUS 0.75 MG PO TABS","81000008","CDM","0250","RC","J7527","HCPCS","51991-381-60","NDC","facility","inpatient","0.339861","UN",,"65.07","65.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EVEROLIMUS 0.5 MG PO TABS","81000008","CDM","0250","RC","J7527","HCPCS","67877-719-33","NDC","facility","inpatient","0.563492","UN",,"65.23","65.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EVEROLIMUS 0.5 MG PO TABS","81000008","CDM","0250","RC","J7527","HCPCS","51991-380-99","NDC","facility","inpatient","0.500000","UN",,"65.07","65.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARFORMOTEROL TARTRATE 15 MCG/2ML IN NEBU","81000008","CDM","0250","RC","J7605","HCPCS","63402-911-30","NDC","facility","inpatient","2.000000","ML",,"94.55","94.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARFORMOTEROL TARTRATE 15 MCG/2ML IN NEBU","81000008","CDM","0250","RC","J7605","HCPCS","69097-168-87","NDC","facility","inpatient","2.000000","ML",,"81.04","81.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARFORMOTEROL TARTRATE 15 MCG/2ML IN NEBU","81000008","CDM","0250","RC","J7605","HCPCS","70756-612-12","NDC","facility","inpatient","2.000000","ML",,"81.44","81.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % ORAL SOLN CUSTOM CREATE","81000008","CDM","0250","RC","J7608","HCPCS","63323-692-10","NDC","facility","inpatient","1.500000","ML",,"31","31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","63323-693-10","NDC","facility","inpatient","5.722222","ML",,"69.79","69.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","63323-694-04","NDC","facility","inpatient","3.403508","ML",,"58.04","58.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","63323-695-04","NDC","facility","inpatient","3.000000","ML",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","63323-691-30","NDC","facility","inpatient","5.333333","ML",,"23.38","23.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","0517-7604-25","NDC","facility","inpatient","5.000000","ML",,"55.82","55.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","0517-7504-25","NDC","facility","inpatient","3.413333","ML",,"50.29","50.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % ORAL SOLN CUSTOM CREATE","81000008","CDM","0250","RC","J7608","HCPCS","0517-7604-01","NDC","facility","inpatient","3.352487","ML",,"55.99","55.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","0409-3307-03","NDC","facility","inpatient","3.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","0409-3307-11","NDC","facility","inpatient","5.000000","ML",,"15.56","15.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % ORAL SOLN CUSTOM CREATE","81000008","CDM","0250","RC","J7608","HCPCS","0409-3308-03","NDC","facility","inpatient","3.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0250","RC","J7608","HCPCS","0517-7504-01","NDC","facility","inpatient","3.229548","ML",,"49.73","49.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU","81000008","CDM","0250","RC","J7611","HCPCS","0487-9901-30","NDC","facility","inpatient","0.393586","UN",,"2.18","2.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL CONTINUOUS NEB SIMPLE SH","81000008","CDM","0250","RC","J7611","HCPCS","69374-330-05","NDC","facility","inpatient","0.245947","ML",,"2.12","2.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","81000008","CDM","0250","RC","J7613","HCPCS","0378-8270-93","NDC","facility","inpatient","1.034482","ML",,"4.87","4.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","81000008","CDM","0250","RC","J7613","HCPCS","0487-9501-01","NDC","facility","inpatient","1.072195","ML",,"4.66","4.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU","81000008","CDM","0250","RC","J7613","HCPCS","0487-9904-01","NDC","facility","inpatient","1.500000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","81000008","CDM","0250","RC","J7613","HCPCS","60687-395-83","NDC","facility","inpatient","1.085106","ML",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","81000008","CDM","0250","RC","J7613","HCPCS","76204-200-01","NDC","facility","inpatient","1.192644","ML",,"4.20","4.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 0.25 MG/2ML IN SUSP","81000008","CDM","0250","RC","J7626","HCPCS","0093-6815-73","NDC","facility","inpatient","2.000000","ML",,"51.78","51.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 0.5 MG/2ML IN SUSP","81000008","CDM","0250","RC","J7626","HCPCS","0093-6816-73","NDC","facility","inpatient","1.666666","ML",,"46.82","46.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 0.25 MG/2ML IN SUSP","81000008","CDM","0250","RC","J7626","HCPCS","0487-9601-01","NDC","facility","inpatient","2.044198","ML",,"52.18","52.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 0.5 MG/2ML IN SUSP","81000008","CDM","0250","RC","J7626","HCPCS","0487-9701-01","NDC","facility","inpatient","1.527272","ML",,"41.75","41.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 0.5 MG/2ML IN SUSP","81000008","CDM","0250","RC","J7626","HCPCS","16714-019-05","NDC","facility","inpatient","2.000000","ML",,"48.81","48.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 0.5 MG/2ML IN SUSP","81000008","CDM","0250","RC","J7626","HCPCS","60687-524-83","NDC","facility","inpatient","1.950495","ML",,"48.06","48.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 0.5 MG/2ML IN SUSP","81000008","CDM","0250","RC","J7626","HCPCS","68180-984-30","NDC","facility","inpatient","2.000000","ML",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUDESONIDE 0.5 MG/2ML IN SUSP","81000008","CDM","0250","RC","J7626","HCPCS","69097-319-32","NDC","facility","inpatient","1.608695","ML",,"43.05","43.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORNASE ALFA 2.5 MG/2.5ML IN SOLN","81000008","CDM","0250","RC","J7639","HCPCS","50242-100-40","NDC","facility","inpatient","0.998315","ML",,"164.98","164.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM BROMIDE 0.02 % IN SOLN","81000008","CDM","0250","RC","J7644","HCPCS","0487-9801-01","NDC","facility","inpatient","2.570582","ML",,"14.65","14.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM BROMIDE 0.02 % IN SOLN","81000008","CDM","0250","RC","J7644","HCPCS","60687-394-83","NDC","facility","inpatient","2.583333","ML",,"14.85","14.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM BROMIDE 0.02 % IN SOLN","81000008","CDM","0250","RC","J7644","HCPCS","76204-100-01","NDC","facility","inpatient","2.547709","ML",,"14.87","14.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 300 MG/5ML IN NEBU","81000008","CDM","0250","RC","J7682","HCPCS","0078-0494-71","NDC","facility","inpatient","5.000000","ML",,"529.47","529.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 300 MG/5ML IN NEBU","81000008","CDM","0250","RC","J7682","HCPCS","43598-605-04","NDC","facility","inpatient","6.212121","ML",,"386.31","386.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 300 MG/5ML IN NEBU","81000008","CDM","0250","RC","J7682","HCPCS","68180-962-56","NDC","facility","inpatient","5.000000","ML",,"424.08","424.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.2% IV SOLN","81000008","CDM","0250","RC","J7799","HCPCS","0264-7616-00","NDC","facility","inpatient","500.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.2% IV SOLN","81000008","CDM","0250","RC","J7799","HCPCS","0338-0077-04","NDC","facility","inpatient","519.277108","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.2% IV SOLN","81000008","CDM","0250","RC","J7799","HCPCS","63323-873-10","NDC","facility","inpatient","500.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 2 MG PO TABS","81000008","CDM","0250","RC","J8540","HCPCS","0054-8176-25","NDC","facility","inpatient","0.127952","UN",,"1.78","1.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 0.5 MG PO TABS","81000008","CDM","0250","RC","J8540","HCPCS","0054-8179-25","NDC","facility","inpatient","0.713333","UN",,"6","6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 1.5 MG PO TABS","81000008","CDM","0250","RC","J8540","HCPCS","0054-8181-25","NDC","facility","inpatient","0.166666","UN",,"1.35","1.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 4 MG PO TABS","81000008","CDM","0250","RC","J8540","HCPCS","0904-7266-61","NDC","facility","inpatient","0.066421","UN",,"0.68","0.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 4 MG PO TABS","81000008","CDM","0250","RC","J8540","HCPCS","0054-8175-25","NDC","facility","inpatient","0.063317","UN",,"0.69","0.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 0.5 MG/5ML PO SOLN","81000008","CDM","0250","RC","J8540","HCPCS","0054-3177-63","NDC","facility","inpatient","0.601142","ML",,"28.42","28.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 1 MG/ML PO CONC","81000008","CDM","0250","RC","J8540","HCPCS","0054-3176-44","NDC","facility","inpatient","0.249887","ML",,"2.65","2.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHOTREXATE SODIUM 2.5 MG PO TABS","81000008","CDM","0250","RC","J8610","HCPCS","50268-527-11","NDC","facility","inpatient","1.000000","UN",,"23.17","23.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TEMOZOLOMIDE 140 MG PO CAPS","81000008","CDM","0250","RC","J8700","HCPCS","47335-929-72","NDC","facility","inpatient","0.035714","UN",,"40.76","40.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0250","RC","J9000","HCPCS","0069-3031-20","NDC","facility","inpatient","4.801504","ML","JZ","156.32","156.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0250","RC","J9000","HCPCS","0069-3032-20","NDC","facility","inpatient","4.794117","ML","JZ","45.80","45.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0250","RC","J9000","HCPCS","0143-9085-01","NDC","facility","inpatient","4.224615","ML","JZ","110.71","110.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0250","RC","J9000","HCPCS","0143-9086-01","NDC","facility","inpatient","4.780240","ML","JZ","60.24","60.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0250","RC","J9000","HCPCS","25021-207-25","NDC","facility","inpatient","4.876391","ML","JZ","51.59","51.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0250","RC","J9000","HCPCS","63323-883-30","NDC","facility","inpatient","4.714285","ML","JZ","58.57","58.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 50 MG IV SOLR","81000008","CDM","0250","RC","J9000","HCPCS","67457-436-50","NDC","facility","inpatient","0.179000","UN","JZ","340.42","340.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0250","RC","J9000","HCPCS","0069-0277-02","NDC","facility","inpatient","3.580000","ML",,"150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARSENIC TRIOXIDE 12 MG/6ML IV SOLN","81000008","CDM","0250","RC","J9017","HCPCS","70121-1658-1","NDC","facility","inpatient","0.455357","ML","JZ","303.05","303.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ARSENIC TRIOXIDE 12 MG/6ML IV SOLN","81000008","CDM","0250","RC","J9017","HCPCS","70121-1658-6","NDC","facility","inpatient","0.463636","ML","JZ","308.56","308.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ARSENIC TRIOXIDE 12 MG/6ML IV SOLN","81000008","CDM","0250","RC","J9017","HCPCS","70710-1610-1","NDC","facility","inpatient","0.597656","ML","JZ","307.04","307.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ARSENIC TRIOXIDE 12 MG/6ML IV SOLN","81000008","CDM","0250","RC","J9017","HCPCS","70710-1610-6","NDC","facility","inpatient","0.450000","ML","JZ","315.24","315.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATEZOLIZUMAB 1200 MG/20ML IV SOLN","81000008","CDM","0250","RC","J9022","HCPCS","50242-917-01","NDC","facility","inpatient","0.166666","ML","JZ","159.52","159.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZACITIDINE 100 MG/10ML IJ SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J9025","HCPCS","43598-305-62","NDC","facility","inpatient","0.009994","UN","JZ","15.59","15.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZACITIDINE 100 MG/10ML IJ SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J9025","HCPCS","59572-102-01","NDC","facility","inpatient","0.010000","UN","JZ","42.28","42.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZACITIDINE 100 MG IJ SUSR","81000008","CDM","0250","RC","J9025","HCPCS","71288-115-30","NDC","facility","inpatient","0.012281","UN","JZ","3.50","3.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZACITIDINE 100 MG/10ML IJ SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J9025","HCPCS","72485-201-01","NDC","facility","inpatient","0.025331","UN","JZ","39.10","39.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BENDAMUSTINE HCL 100 MG/4ML IV SOLN","81000008","CDM","0250","RC","J9034","HCPCS","63459-348-04","NDC","facility","inpatient","0.039789","ML",,"103.35","103.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BLINATUMOMAB 35 MCG IV SOLR","81000008","CDM","0250","RC","J9039","HCPCS","55513-160-01","NDC","facility","inpatient","0.051428","UN",,"482.14","482.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BLEOMYCIN SULFATE 30 UNITS IJ SOLR","81000008","CDM","0250","RC","J9040","HCPCS","16714-908-01","NDC","facility","inpatient","0.500000","UN","JZ","312.32","312.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BORTEZOMIB 3.5 MG IJ SOLR","81000008","CDM","0250","RC","J9041","HCPCS","10019-991-01","NDC","facility","inpatient","0.027639","UN","JZ","14.65","14.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BORTEZOMIB 3.5 MG IJ SOLR","81000008","CDM","0250","RC","J9041","HCPCS","55150-337-01","NDC","facility","inpatient","0.028007","UN","JZ","16.28","16.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BRENTUXIMAB VEDOTIN 50 MG IV SOLR","81000008","CDM","0250","RC","J9042","HCPCS","51144-050-01","NDC","facility","inpatient","0.020000","UN","JZ","406.87","406.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0250","RC","J9045","HCPCS","0703-4239-01","NDC","facility","inpatient","5.000000","ML",,"48.88","48.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0250","RC","J9045","HCPCS","0703-4246-01","NDC","facility","inpatient","0.059000","ML",,"300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0250","RC","J9045","HCPCS","16729-295-12","NDC","facility","inpatient","4.090298","ML",,"71.20","71.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0250","RC","J9045","HCPCS","55150-335-01","NDC","facility","inpatient","4.730000","ML",,"41.74","41.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0250","RC","J9045","HCPCS","55150-386-01","NDC","facility","inpatient","4.456336","ML",,"45.40","45.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0250","RC","J9045","HCPCS","61703-339-50","NDC","facility","inpatient","4.488526","ML",,"49.43","49.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0250","RC","J9045","HCPCS","61703-339-56","NDC","facility","inpatient","4.713262","ML",,"46.10","46.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BORTEZOMIB 3.5 MG IV SOLR","81000008","CDM","0250","RC","J9046","HCPCS","43598-426-60","NDC","facility","inpatient","0.028060","UN","JZ","54.72","54.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BORTEZOMIB 3.5 MG IV SOLR","81000008","CDM","0250","RC","J9046","HCPCS","43598-865-60","NDC","facility","inpatient","0.028060","UN","JZ","267.86","267.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CARFILZOMIB 60 MG IV SOLR","81000008","CDM","0250","RC","J9047","HCPCS","76075-101-01","NDC","facility","inpatient","0.016664","UN","JZ","137.13","137.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CARFILZOMIB 30 MG IV SOLR","81000008","CDM","0250","RC","J9047","HCPCS","76075-102-01","NDC","facility","inpatient","0.033333","UN","JZ","250","250",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CARFILZOMIB 10 MG IV SOLR","81000008","CDM","0250","RC","J9047","HCPCS","76075-103-01","NDC","facility","inpatient","0.100000","UN","JZ","395.04","395.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CETUXIMAB 100 MG/50ML IV SOLN","81000008","CDM","0250","RC","J9055","HCPCS","66733-958-23","NDC","facility","inpatient","5.000000","ML","JZ","225","225",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CETUXIMAB 100 MG/50ML IV SOLN","81000008","CDM","0250","RC","J9055","HCPCS","66733-948-23","NDC","facility","inpatient","5.000000","ML","JZ","520","520",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9060","HCPCS","0703-5747-11","NDC","facility","inpatient","8.911111","ML",,"66.67","66.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9060","HCPCS","16729-288-38","NDC","facility","inpatient","9.437500","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9060","HCPCS","63323-103-51","NDC","facility","inpatient","9.125000","ML",,"56.34","56.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9060","HCPCS","63323-103-65","NDC","facility","inpatient","9.588938","ML",,"39.21","39.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9060","HCPCS","0143-9504-01","NDC","facility","inpatient","7.342666","ML",,"61.02","61.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIVANTAMAB-VMJW 350 MG/7ML IV SOLN","81000008","CDM","0250","RC","J9061","HCPCS","57894-501-01","NDC","facility","inpatient","0.040000","ML","JZ","71.64","71.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J9070","HCPCS","10019-955-01","NDC","facility","inpatient","0.189054","UN","JZ","470.01","470.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J9070","HCPCS","10019-956-01","NDC","facility","inpatient","0.094997","UN","JZ","526.22","526.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 2000 MG/100ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J9070","HCPCS","10019-957-01","NDC","facility","inpatient","0.050000","UN","JZ","375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG IJ SOLR","81000008","CDM","0250","RC","J9070","HCPCS","70121-1238-1","NDC","facility","inpatient","0.182372","UN","JZ","476.41","476.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1 G IJ SOLR","81000008","CDM","0250","RC","J9070","HCPCS","70121-1239-1","NDC","facility","inpatient","0.100000","UN","JZ","514.22","514.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 2 G IJ SOLR","81000008","CDM","0250","RC","J9070","HCPCS","70121-1240-1","NDC","facility","inpatient","0.049130","UN","JZ","374.12","374.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/2.5ML IV SOLN","81000008","CDM","0250","RC","J9070","HCPCS","70860-218-03","NDC","facility","inpatient","0.481521","ML","JZ","466.83","466.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J9075","HCPCS","10019-955-01","NDC","facility","inpatient","0.012752","UN","JZ","28.49","28.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J9075","HCPCS","10019-956-01","NDC","facility","inpatient","0.004993","UN","JZ","23.23","23.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 2000 MG/100ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J9075","HCPCS","10019-957-01","NDC","facility","inpatient","0.002500","UN","JZ","19.15","19.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J9075","HCPCS","16714-859-01","NDC","facility","inpatient","0.009939","UN","JZ","26.74","26.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0250","RC","J9075","HCPCS","65219-131-20","NDC","facility","inpatient","0.004981","UN","JZ","13.99","13.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/2.5ML IV SOLN","81000008","CDM","0250","RC","J9075","HCPCS","70860-218-03","NDC","facility","inpatient","0.024931","ML","JZ","24.57","24.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/2.5ML IV SOLN","81000008","CDM","0250","RC","J9075","HCPCS","70860-218-10","NDC","facility","inpatient","0.025000","ML","JZ","21.98","21.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/2.5ML IV SOLN","81000008","CDM","0250","RC","J9075","HCPCS","70860-218-10","NDC","facility","inpatient","0.024982","ML",,"23.06","23.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYTARABINE 20 MG/ML IJ SOLN","81000008","CDM","0250","RC","J9100","HCPCS","61703-303-46","NDC","facility","inpatient","4.550000","ML",,"66.67","66.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYTARABINE (PF) 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J9100","HCPCS","63323-120-20","NDC","facility","inpatient","1.204716","ML",,"8.09","8.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYTARABINE (PF) 100 MG/ML IJ SOLN","81000008","CDM","0250","RC","J9100","HCPCS","61703-319-22","NDC","facility","inpatient","1.490070","ML","JZ","8.36","8.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYTARABINE 20MG/ML CHEMO IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0250","RC","J9100","HCPCS","61703-305-38","NDC","facility","inpatient","4.666535","ML","JZ","156.52","156.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML IV SOLN","81000008","CDM","0250","RC","J9118","HCPCS","72694-515-01","NDC","facility","inpatient","0.013333","ML","JZ","129.95","129.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DACTINOMYCIN 0.5 MG IV SOLR","81000008","CDM","0250","RC","J9120","HCPCS","39822-2100-2","NDC","facility","inpatient","1.000000","UN","JZ","5200","5200",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DACTINOMYCIN 0.5 MG IV SOLR","81000008","CDM","0250","RC","J9120","HCPCS","55150-431-01","NDC","facility","inpatient","1.000000","UN","JZ","7500","7500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DACTINOMYCIN 0.5 MG IV SOLR","81000008","CDM","0250","RC","J9120","HCPCS","55150-928-02","NDC","facility","inpatient","5.000000","UN","JZ","7500","7500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DARATUMUMAB 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9145","HCPCS","57894-505-05","NDC","facility","inpatient","1.500000","ML","JZ","375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DARATUMUMAB 400 MG/20ML IV SOLN","81000008","CDM","0250","RC","J9145","HCPCS","57894-505-20","NDC","facility","inpatient","1.500000","ML","JZ","168.75","168.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAUNORUBICIN-CYTARABINE LIPO 44 MG/20ML IV SUSR (WET SOLR VIAL)","81000008","CDM","0250","RC","J9153","HCPCS","68727-745-02","NDC","facility","inpatient","0.022727","UN","JZ","417.27","417.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOCETAXEL 20 MG/2ML IV SOLN","81000008","CDM","0250","RC","J9171","HCPCS","0409-0201-02","NDC","facility","inpatient","0.100000","ML","JZ","27.22","27.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOCETAXEL 80 MG/4ML IV CONC","81000008","CDM","0250","RC","J9171","HCPCS","25021-245-04","NDC","facility","inpatient","0.050000","ML","JZ","8.29","8.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOCETAXEL 20 MG/2ML IV SOLN","81000008","CDM","0250","RC","J9171","HCPCS","62332-678-02","NDC","facility","inpatient","0.100000","ML","JZ","108.81","108.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOCETAXEL 80 MG/8ML IV SOLN","81000008","CDM","0250","RC","J9171","HCPCS","0409-0201-10","NDC","facility","inpatient","0.100000","ML",,"24.58","24.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOCETAXEL 80 MG/8ML IV SOLN","81000008","CDM","0250","RC","J9171","HCPCS","67457-532-08","NDC","facility","inpatient","0.099958","ML",,"26.79","26.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DURVALUMAB 500 MG/10ML IV SOLN","81000008","CDM","0250","RC","J9173","HCPCS","0310-4611-50","NDC","facility","inpatient","0.200000","ML","JZ","142.85","142.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENFORTUMAB VEDOTIN-EJFV 20 MG/2ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J9177","HCPCS","51144-020-01","NDC","facility","inpatient","0.012476","UN","JZ","86.26","86.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENFORTUMAB VEDOTIN-EJFV 30 MG/3ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J9177","HCPCS","51144-030-01","NDC","facility","inpatient","0.008312","UN","JZ","115.88","115.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9181","HCPCS","0143-9510-01","NDC","facility","inpatient","0.710131","ML",,"26.64","26.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9181","HCPCS","0143-9511-01","NDC","facility","inpatient","0.799367","ML",,"22.99","22.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9181","HCPCS","16729-114-08","NDC","facility","inpatient","0.483494","ML",,"24.14","24.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9181","HCPCS","16729-114-31","NDC","facility","inpatient","0.640270","ML",,"25.93","25.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9181","HCPCS","63323-104-05","NDC","facility","inpatient","0.487514","ML",,"19.53","19.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9181","HCPCS","63323-104-06","NDC","facility","inpatient","0.490600","ML",,"24","24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9181","HCPCS","63323-104-25","NDC","facility","inpatient","0.597650","ML",,"19.90","19.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","16729-276-68","NDC","facility","inpatient","8.883018","ML","JZ","119.02","119.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","25021-215-98","NDC","facility","inpatient","9.486792","ML","JZ","63.64","63.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","62332-751-50","NDC","facility","inpatient","10.530526","ML","JZ","66.74","66.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","62332-779-31","NDC","facility","inpatient","9.942045","ML","JZ","44.49","44.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","63323-117-00","NDC","facility","inpatient","10.000000","ML","JZ","100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","63323-117-10","NDC","facility","inpatient","10.116666","ML","JZ","97.92","97.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","63323-117-20","NDC","facility","inpatient","9.828225","ML","JZ","61.25","61.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","63323-117-51","NDC","facility","inpatient","13.110891","ML","JZ","54.84","54.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","63323-117-61","NDC","facility","inpatient","9.883333","ML","JZ","50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","70700-189-22","NDC","facility","inpatient","9.787500","ML","JZ","44.40","44.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","16729-276-38","NDC","facility","inpatient","9.464516","ML","JZ","64.77","64.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9190","HCPCS","25021-215-98","NDC","facility","inpatient","9.350000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMCITABINE HCL 200 MG/2ML IV SOLN","81000008","CDM","0250","RC","J9196","HCPCS","16729-391-30","NDC","facility","inpatient","2.000000","ML",,"343.2","343.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMCITABINE HCL 1 GM/10ML IV SOLN","81000008","CDM","0250","RC","J9196","HCPCS","16729-419-03","NDC","facility","inpatient","4.909090","ML",,"102.96","102.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0250","RC","J9201","HCPCS","0409-0186-01","NDC","facility","inpatient","0.200000","GM",,"79.22","79.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMCITABINE HCL 200 MG/5.26ML IV SOLN","81000008","CDM","0250","RC","J9201","HCPCS","0409-0183-01","NDC","facility","inpatient","3.544238","ML","JZ","100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0250","RC","J9201","HCPCS","16714-930-01","NDC","facility","inpatient","0.200000","UN","JZ","77.82","77.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0250","RC","J9201","HCPCS","63323-125-53","NDC","facility","inpatient","0.175000","UN","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 GM/26.3ML IV SOLN","81000008","CDM","0250","RC","J9201","HCPCS","71288-117-28","NDC","facility","inpatient","11.856040","ML","JZ","60","60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 200 MG IV SOLR","81000008","CDM","0250","RC","J9201","HCPCS","0409-0185-01","NDC","facility","inpatient","200.000000","ME",,"85.33","85.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMCITABINE HCL 1 GM/26.3ML IV SOLN","81000008","CDM","0250","RC","J9201","HCPCS","0409-0181-01","NDC","facility","inpatient","5.188391","ML","JZ","68.60","68.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMTUZUMAB OZOGAMICIN 4.5 MG/4.5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J9203","HCPCS","0008-4510-01","NDC","facility","inpatient","0.021931","UN","JZ","384.93","384.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9206","HCPCS","60505-6128-0","NDC","facility","inpatient","7.875000","ML","JZ","53.44","53.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9206","HCPCS","60505-6128-1","NDC","facility","inpatient","2.454635","ML","JZ","44.96","44.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MESNA 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J9209","HCPCS","25021-201-10","NDC","facility","inpatient","1.700000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESNA 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J9209","HCPCS","10019-953-01","NDC","facility","inpatient","1.821329","ML",,"73.24","73.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESNA 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J9209","HCPCS","0338-1305-01","NDC","facility","inpatient","3.222222","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MESNA 100 MG/ML IV SOLN","81000008","CDM","0250","RC","J9209","HCPCS","0143-9260-01","NDC","facility","inpatient","1.886666","ML",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IDARUBICIN HCL 20 MG/20ML IV SOLN","81000008","CDM","0250","RC","J9211","HCPCS","0013-2586-91","NDC","facility","inpatient","4.500000","ML","JZ","378.32","378.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IDARUBICIN 1MG/ML CHEMO IV PUSH SH","81000008","CDM","0250","RC","J9211","HCPCS","0013-2596-91","NDC","facility","inpatient","4.461538","ML","JZ","358.71","358.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IDARUBICIN 1MG/ML CHEMO IV PUSH SH","81000008","CDM","0250","RC","J9211","HCPCS","0143-9218-01","NDC","facility","inpatient","4.566666","ML","JZ","482.46","482.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IDARUBICIN 1MG/ML CHEMO IV PUSH SH","81000008","CDM","0250","RC","J9211","HCPCS","0143-9219-01","NDC","facility","inpatient","4.687500","ML","JZ","428.32","428.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUPROLIDE ACETATE 7.5 MG IM KIT","81000008","CDM","0250","RC","J9217","HCPCS","0074-3642-03","NDC","facility","inpatient","1.000000","UN","JZ","8483.01","8483.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ISATUXIMAB-IRFC 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9227","HCPCS","0024-0654-01","NDC","facility","inpatient","8.500000","ML","JZ","324.32","324.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ISATUXIMAB-IRFC 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9227","HCPCS","0024-0656-01","NDC","facility","inpatient","0.833333","ML","JZ","270","270",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ISATUXIMAB-IRFC 100 MG/5ML IV SOLN","81000008","CDM","0250","RC","J9227","HCPCS","0024-0654-01","NDC","facility","inpatient","0.500000","ML",,"306.25","306.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPILIMUMAB 50 MG/10ML IV SOLN","81000008","CDM","0250","RC","J9228","HCPCS","0003-2327-11","NDC","facility","inpatient","0.200000","ML","JZ","307.17","307.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE 25MG/ML CHEMO IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0250","RC","J9255","HCPCS","16729-277-30","NDC","facility","inpatient","0.480000","ML","JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR","81000008","CDM","0250","RC","J9259","HCPCS","0517-4300-01","NDC","facility","inpatient","0.010000","UN","JZ","57.45","57.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J9260","HCPCS","0143-9519-10","NDC","facility","inpatient","0.793239","ML","JZ","293.57","293.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN","81000008","CDM","0250","RC","J9260","HCPCS","0703-3671-03","NDC","facility","inpatient","0.510000","ML","JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN","81000008","CDM","0250","RC","J9260","HCPCS","0703-3678-01","NDC","facility","inpatient","1.995705","ML","JZ","15.35","15.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN","81000008","CDM","0250","RC","J9260","HCPCS","61703-408-41","NDC","facility","inpatient","1.995156","ML","JZ","14.38","14.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9263","HCPCS","60505-6132-7","NDC","facility","inpatient","0.500000","ML",,"3.9","3.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9263","HCPCS","0781-3315-70","NDC","facility","inpatient","0.100000","ML","JZ","13.79","13.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9263","HCPCS","0781-3317-80","NDC","facility","inpatient","0.100000","ML","JZ","13.79","13.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9263","HCPCS","60505-6132-6","NDC","facility","inpatient","0.100000","ML","JZ","3.92","3.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","J9263","HCPCS","60505-6132-7","NDC","facility","inpatient","0.100000","ML","JZ","3.89","3.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"STUDY RX: INVESTIGATIONAL PACLITAXEL PROTEIN-BOUND 100MG IV SUSR","81000008","CDM","0250","RC","J9264","HCPCS","68817-134-50","NDC","facility","inpatient","0.009966","UN",,"66.14","66.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0250","RC","J9267","HCPCS","16714-137-01","NDC","facility","inpatient","0.166666","ML",,"4.35","4.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0250","RC","J9267","HCPCS","25021-255-17","NDC","facility","inpatient","0.166666","ML",,"2.38","2.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0250","RC","J9267","HCPCS","25021-255-50","NDC","facility","inpatient","0.166666","ML",,"1.78","1.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0250","RC","J9267","HCPCS","61703-342-22","NDC","facility","inpatient","0.303187","ML",,"3.39","3.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0250","RC","J9267","HCPCS","61703-342-50","NDC","facility","inpatient","0.166666","ML",,"1.90","1.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0250","RC","J9267","HCPCS","63323-763-16","NDC","facility","inpatient","0.165785","ML",,"3.38","3.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0250","RC","J9267","HCPCS","70860-200-50","NDC","facility","inpatient","0.166453","ML",,"3.52","3.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PEMBROLIZUMAB 100 MG/4ML IV SOLN","81000008","CDM","0250","RC","J9271","HCPCS","0006-3026-02","NDC","facility","inpatient","0.040000","ML","JZ","103.44","103.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML IV SOLN","81000008","CDM","0250","RC","J9298","HCPCS","0003-7125-11","NDC","facility","inpatient","0.250000","ML","JZ","326.98","326.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NIVOLUMAB 240 MG/24ML IV SOLN","81000008","CDM","0250","RC","J9299","HCPCS","0003-3734-13","NDC","facility","inpatient","0.150000","ML","JZ","58.33","58.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 100 MG IV SOLR","81000008","CDM","0250","RC","J9305","HCPCS","43598-386-62","NDC","facility","inpatient","0.100000","UN","JZ","124.02","124.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J9305","HCPCS","43598-387-11","NDC","facility","inpatient","0.020000","UN","JZ","79.37","79.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 100 MG IV SOLR","81000008","CDM","0250","RC","J9305","HCPCS","71288-166-10","NDC","facility","inpatient","0.100000","UN","JZ","23.4","23.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J9305","HCPCS","71288-167-50","NDC","facility","inpatient","0.020000","UN","JZ","23.4","23.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J9305","HCPCS","0338-0722-01","NDC","facility","inpatient","0.020000","UN","JZ","23.4","23.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SACITUZUMAB GOVITECAN-HZIY 180 MG/18ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J9317","HCPCS","55135-132-01","NDC","facility","inpatient","0.013888","UN","JZ","80.36","80.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TREMELIMUMAB-ACTL 300 MG/15ML IV SOLN","81000008","CDM","0250","RC","J9347","HCPCS","0310-4535-30","NDC","facility","inpatient","0.050000","ML","JZ","234","234",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0250","RC","J9358","HCPCS","65597-406-01","NDC","facility","inpatient","0.010000","UN","JZ","67.5","67.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VINCRISTINE SULFATE 1 MG/ML IV SOLN","81000008","CDM","0250","RC","J9370","HCPCS","61703-309-06","NDC","facility","inpatient","0.764943","ML","JZ","288.61","288.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VINCRISTINE SULFATE 1 MG/ML IV SOLN","81000008","CDM","0250","RC","J9370","HCPCS","61703-309-16","NDC","facility","inpatient","0.978378","ML","JZ","150.34","150.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0250","RC","P9041","HCPCS","68516-5214-4","NDC","facility","inpatient","58.717948","ML","JZ","55.88","55.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0250","RC","P9041","HCPCS","68516-5214-6","NDC","facility","inpatient","50.000000","ML","JZ","250","250",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0250","RC","P9041","HCPCS","44206-310-25","NDC","facility","inpatient","51.342281","ML",,"88.30","88.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0250","RC","P9041","HCPCS","68516-5214-3","NDC","facility","inpatient","51.694915","ML","JZ","66.9","66.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0250","RC","P9041","HCPCS","68516-5214-2","NDC","facility","inpatient","58.888888","ML","JZ","42.32","42.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0250","RC","P9041","HCPCS","68516-5214-1","NDC","facility","inpatient","50.000000","ML","JZ","66.9","66.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN SH (VOLUME REPLACEMENT)","81000008","CDM","0250","RC","P9041","HCPCS","68209-623-03","NDC","facility","inpatient","50.000000","ML","JZ","66.6","66.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN SH (VOLUME REPLACEMENT)","81000008","CDM","0250","RC","P9041","HCPCS","0944-0495-05","NDC","facility","inpatient","50.000000","ML","JZ","55.6","55.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0250","RC","P9041","HCPCS","44206-310-25","NDC","facility","inpatient","52.218061","ML","JZ","107.43","107.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0250","RC","P9041","HCPCS","44206-310-50","NDC","facility","inpatient","55.729539","ML","JZ","82.23","82.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0250","RC","P9047","HCPCS","68516-5216-6","NDC","facility","inpatient","16.800000","ML","JZ","255.78","255.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0250","RC","P9047","HCPCS","44206-251-10","NDC","facility","inpatient","50.000000","ML",,"399.83","399.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0250","RC","P9047","HCPCS","68516-5216-5","NDC","facility","inpatient","22.000000","ML","JZ","284.36","284.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0250","RC","P9047","HCPCS","68516-5216-2","NDC","facility","inpatient","51.343518","ML","JZ","276.22","276.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0250","RC","P9047","HCPCS","68516-5216-1","NDC","facility","inpatient","54.566210","ML","JZ","332.22","332.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0250","RC","P9047","HCPCS","68209-643-01","NDC","facility","inpatient","62.500000","ML","JZ","394.5","394.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0250","RC","P9047","HCPCS","44206-251-05","NDC","facility","inpatient","53.065395","ML","JZ","532.37","532.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0250","RC","P9047","HCPCS","44206-251-10","NDC","facility","inpatient","51.687048","ML","JZ","427.27","427.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TOCILIZUMAB 20 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","Q0249","HCPCS","50242-136-01","NDC","facility","inpatient","0.050000","ML","JZ","30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TOCILIZUMAB 20 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","Q0249","HCPCS","50242-137-01","NDC","facility","inpatient","0.050000","ML","JZ","23.90","23.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSPHENYTOIN SODIUM 50 MG PE/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","Q2009","HCPCS","0069-6001-21","NDC","facility","inpatient","1.432518","ML",,"74.32","74.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOSPHENYTOIN SODIUM 50 MG PE/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","Q2009","HCPCS","0069-6001-25","NDC","facility","inpatient","0.974650","ML",,"128.55","128.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOSPHENYTOIN SODIUM 50 MG PE/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0250","RC","Q2009","HCPCS","0641-6136-25","NDC","facility","inpatient","1.722222","ML",,"60.22","60.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0250","RC","Q2050","HCPCS","0338-0063-01","NDC","facility","inpatient","5.000000","ML","JZ","2585.7","2585.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0250","RC","Q2050","HCPCS","47335-049-40","NDC","facility","inpatient","5.000000","ML","JZ","2907","2907",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0250","RC","Q2050","HCPCS","70710-1530-1","NDC","facility","inpatient","4.918750","ML","JZ","2008.45","2008.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0250","RC","Q2050","HCPCS","70710-1531-1","NDC","facility","inpatient","4.720000","ML","JZ","1500","1500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0250","RC","Q2050","HCPCS","72603-200-01","NDC","facility","inpatient","4.980000","ML","JZ","2026.81","2026.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0250","RC","Q2050","HCPCS","0338-0067-01","NDC","facility","inpatient","4.990769","ML","JZ","1500","1500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY","81000008","CDM","0250","RC","Q5101","HCPCS","61314-326-10","NDC","facility","inpatient","0.001732","ML","JZ","5.21","5.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY","81000008","CDM","0250","RC","Q5101","HCPCS","61314-326-01","NDC","facility","inpatient","0.001958","ML","JZ","5.21","5.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY","81000008","CDM","0250","RC","Q5101","HCPCS","61314-318-10","NDC","facility","inpatient","0.001666","ML","JZ","5.17","5.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY","81000008","CDM","0250","RC","Q5101","HCPCS","61314-318-01","NDC","facility","inpatient","0.001806","ML","JZ","5.29","5.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","Q5105","HCPCS","0069-1308-10","NDC","facility","inpatient","0.010000","ML","JZ","8.46","8.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN (ESRD)","81000008","CDM","0250","RC","Q5105","HCPCS","0069-1309-04","NDC","facility","inpatient","0.002500","ML","JZ","6.25","6.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 20,000 UNIT/ML IJ SOLN (ESRD)","81000008","CDM","0250","RC","Q5105","HCPCS","0069-1311-10","NDC","facility","inpatient","0.005000","ML",,"6.62","6.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN (ESRD)","81000008","CDM","0250","RC","Q5106","HCPCS","0069-1309-04","NDC","facility","inpatient","0.032692","ML","JZ","62.5","62.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN (ESRD)","81000008","CDM","0250","RC","Q5106","HCPCS","0069-1306-10","NDC","facility","inpatient","0.333333","ML","JZ","86.03","86.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN (ESRD)","81000008","CDM","0250","RC","Q5106","HCPCS","0069-1307-10","NDC","facility","inpatient","0.250000","ML","JZ","86.04","86.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000008","CDM","0250","RC","Q5106","HCPCS","0069-1308-10","NDC","facility","inpatient","0.107272","ML","JZ","86.03","86.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 20,000 UNIT/ML IJ SOLN (ESRD)","81000008","CDM","0250","RC","Q5106","HCPCS","0069-1311-10","NDC","facility","inpatient","0.083333","ML",,"64.95","64.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN","81000008","CDM","0250","RC","Q5107","HCPCS","55513-206-01","NDC","facility","inpatient","0.399358","ML","JZ","341.06","341.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN","81000008","CDM","0250","RC","Q5107","HCPCS","55513-207-01","NDC","facility","inpatient","0.399814","ML","JZ","187.44","187.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY","81000008","CDM","0250","RC","Q5111","HCPCS","70114-101-01","NDC","facility","inpatient","0.050000","ML","JZ","937.5","937.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-PVVR 100 MG/10ML IV SOLN","81000008","CDM","0250","RC","Q5119","HCPCS","0069-0238-01","NDC","facility","inpatient","1.391599","ML","JZ","387.48","387.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-PVVR 500 MG/50ML IV SOLN","81000008","CDM","0250","RC","Q5119","HCPCS","0069-0249-01","NDC","facility","inpatient","1.087431","ML","JZ","220.66","220.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-PVVR 100 MG/10ML IV SOLN","81000008","CDM","0250","RC","Q5119","HCPCS","0069-0238-01","NDC","facility","inpatient","0.992647","ML",,"298.84","298.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLIXIMAB-AXXQ 100 MG IV SOLR","81000008","CDM","0250","RC","Q5121","HCPCS","55513-670-01","NDC","facility","inpatient","0.100000","UN","JZ","105","105",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-AYOW 300 MCG/0.5ML SC SOSY","81000008","CDM","0250","RC","Q5125","HCPCS","70121-1568-7","NDC","facility","inpatient","0.001666","ML","JZ","3.25","3.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-AYOW 480 MCG/0.8ML SC SOSY","81000008","CDM","0250","RC","Q5125","HCPCS","70121-1570-1","NDC","facility","inpatient","0.001666","ML","JZ","3.18","3.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-AYOW 300 MCG/0.5ML SC SOSY","81000008","CDM","0250","RC","Q5125","HCPCS","70121-1568-1","NDC","facility","inpatient","0.001666","ML","JZ","3.25","3.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SULFUR HEXAFLUORIDE MICROSPH 60.7-25 MG IJ SUSR","81000008","CDM","0250","RC","Q9950","HCPCS","0270-7097-07","NDC","facility","inpatient","0.080000","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFUR HEXAFLUORIDE MICROSPH 60.7-25 MG IJ SUSR","81000008","CDM","0250","RC","Q9950","HCPCS","0270-7099-16","NDC","facility","inpatient","0.073333","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0250","RC","S0020","HCPCS","0409-1159-02","NDC","facility","inpatient","30.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL 0.25 % IJ SOLN","81000008","CDM","0250","RC","S0020","HCPCS","0409-1160-01","NDC","facility","inpatient","16.250000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0250","RC","S0020","HCPCS","0409-1159-01","NDC","facility","inpatient","12.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","S0028","HCPCS","0641-6022-25","NDC","facility","inpatient","2.681818","ML","JZ","72.60","72.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","S0028","HCPCS","63323-739-12","NDC","facility","inpatient","2.340096","ML","JZ","74.8","74.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0250","RC","S0028","HCPCS","67457-433-22","NDC","facility","inpatient","2.492307","ML","JZ","70.01","70.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","S0164","HCPCS","0008-0923-55","NDC","facility","inpatient","1.400277","UN",,"74.31","74.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","S0164","HCPCS","0143-9284-10","NDC","facility","inpatient","1.370748","UN",,"74.67","74.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","S0164","HCPCS","0781-3232-95","NDC","facility","inpatient","6.500000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","S0164","HCPCS","25021-751-10","NDC","facility","inpatient","1.551268","UN",,"74.37","74.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0250","RC","S0164","HCPCS","55150-202-10","NDC","facility","inpatient","1.786488","UN",,"74.43","74.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIFEPRISTONE 200 MG PO TABS","81000008","CDM","0250","RC","S0190","HCPCS","64875-001-01","NDC","facility","inpatient","1.000000","UN",,"129","129",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCAGON HCL (RDNA) 1 MG IJ SOLR","81000008","CDM","0250","RC","X6254","HCPCS","0169-7065-15","NDC","facility","inpatient","0.500000","ME",,"975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU","81000008","CDM","0250","RC","Z7610","HCPCS","0487-9904-01","NDC","facility","inpatient","16.500000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 1 MG PO TABS","81000008","CDM","0250","RC","Z7610","HCPCS","0054-8174-25","NDC","facility","inpatient","0.250000","UN",,"4.04","4.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 0.5 MG PO TABS","81000008","CDM","0250","RC","Z7610","HCPCS","0054-8179-25","NDC","facility","inpatient","0.500000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DILTIAZEM HCL 25 MG/5ML IV SOLN","81000008","CDM","0250","RC","0641-6013-10","NDC",,,"facility","inpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ANTIINHIBITOR COAGULANT CMPLX 500 UNITS IV SOLR","81000008","CDM","0250","RC","64193-426-02","NDC",,,"facility","inpatient","0.002000","UN",,"0.02","0.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE 1MG/ML CADD-SOLIS PCA (PREMIX) SH","81000008","CDM","0250","RC","70092-1522-35","NDC",,,"facility","inpatient","50.000000","ML",,"104.98","104.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE 1MG/ML NS CADD-SOLIS PCA (PREMIX) (PEDIATRIC) SH","81000008","CDM","0250","RC","70092-1546-35","NDC",,,"facility","inpatient","150.000000","ML",,"178.75","178.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN","81000008","CDM","0250","RC","80830-2362-1","NDC",,,"facility","inpatient","53.174603","ML",,"165.9","165.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 15MG/ML ARTIFICIAL TEARS OPHTH SOLN *COMPOUNDED* SH","81000008","CDM","0250","RC","99999-0032-96","NDC",,,"facility","inpatient","15.000000","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5ML IM SOSY","81000008","CDM","0636","RC","90371","HCPCS","13533-636-03","NDC","facility","outpatient","0.500000","ML","JZ","318.42","318.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","90375","HCPCS","13533-318-01","NDC","facility","outpatient","0.500000","ML","JZ","210.04","210.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN","81000008","CDM","0636","RC","90375","HCPCS","13533-318-05","NDC","facility","outpatient","0.484844","ML","JZ","1184.69","1184.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY","81000008","CDM","0636","RC","90384","HCPCS","0562-7805-01","NDC","facility","outpatient","1.000000","UN",,"65.25","65.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VARICELLA-ZOSTER IMMUNE GLOB 125 UNIT/1.2ML IM SOLN","81000008","CDM","0636","RC","90396","HCPCS","70257-126-51","NDC","facility","outpatient","1.200000","ML",,"7857.24","7857.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR","81000008","CDM","0636","RC","90648","HCPCS","49281-545-03","NDC","facility","outpatient","1.000000","UN","JZ","107.48","107.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLUENZA VAC A&B SURF ANT ADJ 0.5 ML IM SUSY","81000008","CDM","0636","RC","90653","HCPCS","70461-024-04","NDC","facility","outpatient","0.500000","ML",,"571.25","571.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY","81000008","CDM","0636","RC","90653","HCPCS","70461-123-03","NDC","facility","outpatient","0.500000","ML",,"529.3","529.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY","81000008","CDM","0636","RC","90653","HCPCS","70461-123-03","NDC","facility","outpatient","0.500000","ML","PN","529.3","529.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"INFLUENZA VIRUS VACC SPLIT PF 0.5 ML IM SUSY","81000008","CDM","0636","RC","90656","HCPCS","19515-810-41","NDC","facility","outpatient","0.500000","ML",,"164.68","164.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RABIES VACCINE, PCEC IM SUSR","81000008","CDM","0636","RC","90675","HCPCS","50090-1820-0","NDC","facility","outpatient","1.000000","UN","JZ","1963.8","1963.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RABIES VACCINE, PCEC IM SUSR","81000008","CDM","0636","RC","90675","HCPCS","50632-010-01","NDC","facility","outpatient","1.103448","UN","JZ","2480.80","2480.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RABIES VACCINE, PCEC IM SUSR","81000008","CDM","0636","RC","90675","HCPCS","50632-013-01","NDC","facility","outpatient","1.000000","UN","JZ","2469.81","2469.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RABIES VACCINE, PCEC IM SUSR","81000008","CDM","0636","RC","90675","HCPCS","63851-501-02","NDC","facility","outpatient","1.000000","UN","JZ","1963.8","1963.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY","81000008","CDM","0636","RC","90686","HCPCS","19515-814-41","NDC","facility","outpatient","0.500000","ML",,"164.68","164.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY","81000008","CDM","0636","RC","90686","HCPCS","19515-814-52","NDC","facility","outpatient","0.928571","ML",,"164.68","164.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY","81000008","CDM","0636","RC","90686","HCPCS","19515-814-52","NDC","facility","outpatient","0.500000","ML","PN","164.68","164.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP","81000008","CDM","0636","RC","90700","HCPCS","58160-810-52","NDC","facility","outpatient","0.500000","ML",,"221.68","221.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEASLES, MUMPS & RUBELLA VAC IJ SOLR","81000008","CDM","0636","RC","90707","HCPCS","0006-4681-00","NDC","facility","outpatient","1.000000","UN","JZ","718.53","718.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP","81000008","CDM","0636","RC","90715","HCPCS","49281-400-10","NDC","facility","outpatient","0.500000","ML","JZ","370.15","370.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP","81000008","CDM","0636","RC","90715","HCPCS","49281-400-58","NDC","facility","outpatient","0.524691","ML","JZ","368.75","368.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP","81000008","CDM","0636","RC","90715","HCPCS","49281-400-20","NDC","facility","outpatient","0.560422","ML",,"369.02","369.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ","81000008","CDM","0636","RC","90732","HCPCS","0006-4837-03","NDC","facility","outpatient","4.500000","ML","JZ","913.25","913.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ","81000008","CDM","0636","RC","90732","HCPCS","0006-4943-00","NDC","facility","outpatient","0.500000","ML","JZ","913.25","913.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MENING ACY&W-135 TETANUS CONJ IM SOLN","81000008","CDM","0636","RC","90734","HCPCS","49281-590-58","NDC","facility","outpatient","0.500000","ML",,"147.7","147.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GADOXETATE DISODIUM 0.25 MMOL/ML IV SOLN","81000008","CDM","0636","RC","A9581","HCPCS","50419-320-01","NDC","facility","outpatient","0.999924","ML","JZ","45.86","45.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOXETATE DISODIUM 0.25 MMOL/ML IV SOLN","81000008","CDM","0636","RC","A9581","HCPCS","50419-320-05","NDC","facility","outpatient","1.000000","ML","JZ","38.46","38.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"COCAINE HCL 4 % EX SOLN","81000008","CDM","0636","RC","C9046","HCPCS","0527-1728-74","NDC","facility","outpatient","0.031666","ML",,"4.18","4.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","C9113","HCPCS","0008-0923-55","NDC","facility","outpatient","3.159695","UN",,"73.78","73.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","C9113","HCPCS","0143-9284-10","NDC","facility","outpatient","2.314381","UN",,"73.39","73.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","C9113","HCPCS","0781-3232-95","NDC","facility","outpatient","9.000000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","C9113","HCPCS","25021-751-10","NDC","facility","outpatient","2.556553","UN",,"70.31","70.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","C9113","HCPCS","55150-202-10","NDC","facility","outpatient","3.226139","UN",,"87.4","87.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLEVIDIPINE 50 MG/100ML IV EMUL","81000008","CDM","0636","RC","C9248","HCPCS","10122-611-10","NDC","facility","outpatient","2.392156","ML","JZ","20.54","20.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LACOSAMIDE 200 MG/20ML IV SOLN","81000008","CDM","0636","RC","C9254","HCPCS","0131-1810-67","NDC","facility","outpatient","0.100000","ML",,"2.32","2.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 200 MG/20ML IV SOLN","81000008","CDM","0636","RC","C9254","HCPCS","25021-791-20","NDC","facility","outpatient","0.100000","ML",,"1.67","1.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACOSAMIDE 200 MG/20ML IV SOLN","81000008","CDM","0636","RC","C9254","HCPCS","70710-1359-1","NDC","facility","outpatient","0.100000","ML",,"1.68","1.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TERLIPRESSIN ACETATE 0.85 MG IV SOLR","81000008","CDM","0636","RC","C9399","HCPCS","43825-200-01","NDC","facility","outpatient","1.000000","UN",,"4560","4560",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CANGRELOR TETRASODIUM 50 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","C9460","HCPCS","10122-620-10","NDC","facility","outpatient","0.020000","UN","JZ","88.63","88.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ABATACEPT 250 MG/10 ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J0129","HCPCS","0003-2187-13","NDC","facility","outpatient","0.062857","UN","PN,JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ABATACEPT 250 MG/10 ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J0129","HCPCS","0003-2187-13","NDC","facility","outpatient","0.040000","UN","PN,JZ,JA","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J0131","HCPCS","55150-307-24","NDC","facility","outpatient","1.269130","ML","JZ","1.72","1.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J0131","HCPCS","43825-102-01","NDC","facility","outpatient","3.578125","ML","JZ","3.79","3.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J0131","HCPCS","24201-100-24","NDC","facility","outpatient","1.414153","ML","JZ","0.94","0.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J0131","HCPCS","0781-3156-95","NDC","facility","outpatient","1.000000","ML","JZ","2.90","2.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0636","RC","J0132","HCPCS","25021-812-30","NDC","facility","outpatient","0.498684","ML","JZ","14.96","14.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0636","RC","J0132","HCPCS","70594-111-02","NDC","facility","outpatient","0.498261","ML","JZ","7.72","7.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0636","RC","J0132","HCPCS","72611-860-04","NDC","facility","outpatient","0.499803","ML","JZ","4.80","4.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETYLCYSTEINE 200 MG/ML IV SOLN","81000008","CDM","0636","RC","J0132","HCPCS","0574-0805-30","NDC","facility","outpatient","0.498098","ML",,"17.61","17.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACYCLOVIR SODIUM 50 MG/ML IV SOLN","81000008","CDM","0636","RC","J0133","HCPCS","63323-325-03","NDC","facility","outpatient","0.101806","ML","JZ","1.54","1.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACYCLOVIR SODIUM 50 MG/ML IV SOLN","81000008","CDM","0636","RC","J0133","HCPCS","63323-325-10","NDC","facility","outpatient","0.099577","ML","JZ","1.48","1.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACYCLOVIR SODIUM 50 MG/ML IV SOLN","81000008","CDM","0636","RC","J0133","HCPCS","63323-325-20","NDC","facility","outpatient","0.110058","ML","JZ","1.47","1.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAMINOPHEN 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J0137","HCPCS","24201-100-24","NDC","facility","outpatient","1.428571","ML","JZ","0.91","0.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADENOSINE 6 MG/2ML IV SOLN","81000008","CDM","0636","RC","J0153","HCPCS","17478-542-02","NDC","facility","outpatient","0.389814","ML","JZ","8.11","8.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN","81000008","CDM","0636","RC","J0153","HCPCS","63323-651-30","NDC","facility","outpatient","0.333333","ML","JZ","11.64","11.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADENOSINE 6 MG/2ML IV SOLN","81000008","CDM","0636","RC","J0153","HCPCS","67457-855-02","NDC","facility","outpatient","0.389870","ML","JZ","9.33","9.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN","81000008","CDM","0636","RC","J0153","HCPCS","0409-1932-01","NDC","facility","outpatient","0.322968","ML","JZ","10.93","10.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0171","HCPCS","42023-159-25","NDC","facility","outpatient","0.100000","ML","JZ","32.14","32.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE PF 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0171","HCPCS","54288-103-10","NDC","facility","outpatient","0.257621","ML","JZ","9.71","9.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE 0.1MG/ML INJ (PEDIATRIC) SH","81000008","CDM","0636","RC","J0171","HCPCS","76329-3318-1","NDC","facility","outpatient","3.000000","ML","JZ","10.5","10.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE 1 MG/10ML IJ SOSY","81000008","CDM","0636","RC","J0171","HCPCS","0409-4933-11","NDC","facility","outpatient","1.000000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE (ANAPHYLAXIS) 30 MG/30ML IJ SOLN","81000008","CDM","0636","RC","J0171","HCPCS","42023-168-01","NDC","facility","outpatient","0.120338","ML",,"6.52","6.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0171","HCPCS","42023-159-25","NDC","facility","outpatient","0.100000","ML","PN","12.48","12.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"EPINEPHRINE PF 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0171","HCPCS","54288-103-10","NDC","facility","outpatient","0.144444","ML","PN,JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0171","HCPCS","42023-159-25","NDC","facility","outpatient","0.108145","ML",,"11.59","11.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPINEPHRINE HCL 0.1 MG/ML IJ SOLN (IO)","81000008","CDM","0636","RC","J0171","HCPCS","0409-4921-34","NDC","facility","outpatient","1.582089","ML","JZ","4.32","4.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADUCANUMAB-AVWA 170 MG/1.7ML IV SOLN","81000008","CDM","0636","RC","J0172","HCPCS","64406-101-01","NDC","facility","outpatient","0.020000","ML","PN,JZ","29.41","29.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADUCANUMAB-AVWA 300 MG/3ML IV SOLN","81000008","CDM","0636","RC","J0172","HCPCS","64406-102-02","NDC","facility","outpatient","0.020000","ML","PN,JZ","27.07","27.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LECANEMAB-IRMB 500 MG/5ML IV SOLN","81000008","CDM","0636","RC","J0174","HCPCS","62856-215-01","NDC","facility","outpatient","0.010000","ML","PN,JZ,Q1","6.12","6.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier Q1: Routine clinical service provided in a clinical research study that is in an approved clinical research study"
"LECANEMAB-IRMB 200 MG/2ML IV SOLN","81000008","CDM","0636","RC","J0174","HCPCS","62856-212-01","NDC","facility","outpatient","0.010000","ML","PN,JZ,Q1","6.25","6.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier Q1: Routine clinical service provided in a clinical research study that is in an approved clinical research study"
"LECANEMAB-IRMB 500 MG/5ML IV SOLN","81000008","CDM","0636","RC","J0174","HCPCS","62856-215-01","NDC","facility","outpatient","0.010000","ML","PN,JZ","6.12","6.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LECANEMAB-IRMB 200 MG/2ML IV SOLN","81000008","CDM","0636","RC","J0174","HCPCS","62856-212-01","NDC","facility","outpatient","0.010000","ML","PN,JZ","6.34","6.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"REMDESIVIR 100 MG IV SOLR","81000008","CDM","0636","RC","J0248","HCPCS","61958-2901-1","NDC","facility","outpatient","0.010000","UN","JZ","25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"REMDESIVIR 100 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J0248","HCPCS","61958-2901-2","NDC","facility","outpatient","0.021764","UN","JZ","28.78","28.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMINOPHYLLINE 25 MG/ML IV SOLN","81000008","CDM","0636","RC","J0280","HCPCS","0409-5921-01","NDC","facility","outpatient","4.500000","ML","JZ","64.41","64.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMINOPHYLLINE 25 MG/ML IV SOLN","81000008","CDM","0636","RC","J0280","HCPCS","0409-5922-01","NDC","facility","outpatient","18.000000","ML","JZ","31.57","31.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMINOPHYLLINE 25 MG/ML IV SOLN","81000008","CDM","0636","RC","J0280","HCPCS","0409-5922-16","NDC","facility","outpatient","1180.808823","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMINOPHYLLINE 25 MG/ML IV SOLN","81000008","CDM","0636","RC","J0280","HCPCS","0409-5922-16","NDC","facility","outpatient","5.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMIODARONE HCL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J0282","HCPCS","67457-153-03","NDC","facility","outpatient","1.338461","ML","JZ","5.76","5.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE LOAD DOSE 150MG/100ML(D5W) SH","81000008","CDM","0636","RC","J0283","HCPCS","43066-150-10","NDC","facility","outpatient","22.891566","ML","JZ","54.08","54.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN","81000008","CDM","0636","RC","J0283","HCPCS","43066-360-20","NDC","facility","outpatient","17.474747","ML","JZ","30.01","30.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPHOTERICIN B 50 MG IV SOLR","81000008","CDM","0636","RC","J0285","HCPCS","39822-1055-5","NDC","facility","outpatient","0.010979","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 500 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0636","RC","J0290","HCPCS","0781-3407-95","NDC","facility","outpatient","0.620370","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0290","HCPCS","0781-3408-95","NDC","facility","outpatient","0.299079","UN",,"29.31","29.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 1,000MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0290","HCPCS","0781-9404-85","NDC","facility","outpatient","26.388888","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0290","HCPCS","0781-9408-95","NDC","facility","outpatient","0.250000","UN",,"29.32","29.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0290","HCPCS","55150-114-20","NDC","facility","outpatient","0.361111","UN",,"27.85","27.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0290","HCPCS","63323-399-23","NDC","facility","outpatient","25.000000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 250 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0636","RC","J0290","HCPCS","66794-220-02","NDC","facility","outpatient","0.800000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0290","HCPCS","0781-3404-95","NDC","facility","outpatient","0.395882","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN 250 MG FOR DILUTION (PEDIATRIC)","81000008","CDM","0636","RC","J0290","HCPCS","0781-3402-95","NDC","facility","outpatient","0.803619","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0290","HCPCS","0781-3404-95","NDC","facility","outpatient","2.025000","UN","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0290","HCPCS","55150-113-10","NDC","facility","outpatient","1.610476","GM","JZ","31.42","31.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR","81000008","CDM","0636","RC","J0295","HCPCS","55150-116-20","NDC","facility","outpatient","0.500000","UN","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0636","RC","J0295","HCPCS","55150-117-20","NDC","facility","outpatient","1.500000","GM","JZ","51.1","51.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0295","HCPCS","0049-0014-83","NDC","facility","outpatient","0.565573","UN",,"61.14","61.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 1.5GM/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0295","HCPCS","0641-6116-10","NDC","facility","outpatient","0.636000","UN",,"50","50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0636","RC","J0295","HCPCS","0641-6117-10","NDC","facility","outpatient","0.605263","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0295","HCPCS","10019-637-33","NDC","facility","outpatient","50.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0295","HCPCS","25021-143-30","NDC","facility","outpatient","0.580000","UN",,"37.8","37.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0636","RC","J0295","HCPCS","55150-117-20","NDC","facility","outpatient","0.602941","UN",,"51.1","51.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0295","HCPCS","67457-349-03","NDC","facility","outpatient","0.500000","UN",,"53.80","53.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN/SULBACTAM 3G/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0295","HCPCS","71288-006-31","NDC","facility","outpatient","0.500000","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0636","RC","J0295","HCPCS","71288-032-20","NDC","facility","outpatient","0.500000","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0636","RC","J0295","HCPCS","72485-417-01","NDC","facility","outpatient","0.521276","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0330","HCPCS","0409-6629-02","NDC","facility","outpatient","1.138933","ML",,"15.31","15.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0330","HCPCS","0781-3411-95","NDC","facility","outpatient","0.250000","ML",,"16.79","16.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0330","HCPCS","71288-719-10","NDC","facility","outpatient","0.536363","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0360","HCPCS","63323-614-55","NDC","facility","outpatient","0.416666","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0360","HCPCS","0641-6231-25","NDC","facility","outpatient","0.714285","ML",,"92","92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0360","HCPCS","63323-614-01","NDC","facility","outpatient","0.623793","ML",,"85.80","85.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE ER 400 MG IM SRER","81000008","CDM","0636","RC","J0401","HCPCS","59148-019-71","NDC","facility","outpatient","0.002500","UN",,"25.38","25.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ARIPIPRAZOLE ER 400 MG IM SRER","81000008","CDM","0636","RC","J0401","HCPCS","59148-019-70","NDC","facility","outpatient","0.002500","UN",,"25.38","25.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 500 MG/250ML NS (VIAL-MATE)","81000008","CDM","0636","RC","J0456","HCPCS","55150-174-10","NDC","facility","outpatient","1.736842","UN",,"67.66","67.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 500 MG/250ML NS (VIAL-MATE)","81000008","CDM","0636","RC","J0456","HCPCS","70860-100-10","NDC","facility","outpatient","1.301369","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZITHROMYCIN 500 MG/250ML NS (VIAL-MATE)","81000008","CDM","0636","RC","J0456","HCPCS","99999-0011-14","NDC","facility","outpatient","379.629629","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"AZTREONAM 1000 MG/4ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0457","HCPCS","0409-0829-11","NDC","facility","outpatient","0.500000","UN","JZ","27.72","27.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZTREONAM 2000 MG/8ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0457","HCPCS","63323-402-20","NDC","facility","outpatient","0.050000","UN","JZ","28.59","28.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZTREONAM 2000 MG/8ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0457","HCPCS","63323-402-20","NDC","facility","outpatient","0.043750","UN",,"28.59","28.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ATROPINE SULFATE 1 MG/10ML IJ SOSY","81000008","CDM","0636","RC","J0461","HCPCS","0409-4911-34","NDC","facility","outpatient","0.366666","ML","JZ","1.44","1.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE (PF) 0.4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0461","HCPCS","0517-0401-25","NDC","facility","outpatient","0.025000","ML","JZ","1.83","1.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE (PF) 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0461","HCPCS","0517-1001-01","NDC","facility","outpatient","0.010000","ML","JZ","1.42","1.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE (PF) 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0461","HCPCS","0517-1010-25","NDC","facility","outpatient","0.010000","ML","JZ","1.05","1.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE 1 MG/10ML IJ SOSY","81000008","CDM","0636","RC","J0461","HCPCS","76329-3339-1","NDC","facility","outpatient","0.438461","ML","JZ","1.65","1.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATROPINE SULFATE (PF) 0.4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0461","HCPCS","0517-1004-01","NDC","facility","outpatient","0.026843","ML","PN","2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ATROPINE SULFATE (PF) 0.4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0461","HCPCS","16729-525-08","NDC","facility","outpatient","0.028030","ML","PN","2.52","2.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DICYCLOMINE HCL 10 MG/ML IM SOLN","81000008","CDM","0636","RC","J0500","HCPCS","58914-080-52","NDC","facility","outpatient","3.142857","ML",,"655.66","655.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BENZTROPINE MESYLATE 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J0515","HCPCS","68382-860-02","NDC","facility","outpatient","1.000000","ML","JZ","190.94","190.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY","81000008","CDM","0636","RC","J0561","HCPCS","60793-700-10","NDC","facility","outpatient","0.166666","ML",,"97.73","97.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY","81000008","CDM","0636","RC","J0561","HCPCS","60793-701-10","NDC","facility","outpatient","0.976190","ML",,"69.53","69.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY","81000008","CDM","0636","RC","J0561","HCPCS","60793-702-10","NDC","facility","outpatient","0.166666","ML","JZ","114.11","114.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BIVALIRUDIN 250MG/50ML IV BOLUS SH","81000008","CDM","0636","RC","J0583","HCPCS","0409-8300-10","NDC","facility","outpatient","0.019785","UN",,"15.48","15.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONABOTULINUMTOXINA 100 UNITS IJ SOLR","81000008","CDM","0636","RC","J0585","HCPCS","0023-1145-01","NDC","facility","outpatient","0.594790","UN","JZ","29.22","29.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALCIUM GLUCONATE-NACL 2-0.675 GM/100ML-% IV SOLN","81000008","CDM","0636","RC","J0610","HCPCS","44567-621-01","NDC","facility","outpatient","10.000000","ML",,"30.81","30.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN","81000008","CDM","0636","RC","J0610","HCPCS","44567-620-24","NDC","facility","outpatient","30.000000","ML",,"33.18","33.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE 10 % IV SOLN","81000008","CDM","0636","RC","J0612","HCPCS","63323-360-19","NDC","facility","outpatient","0.133105","ML",,"0.84","0.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE 10 % IV SOLN","81000008","CDM","0636","RC","J0612","HCPCS","63323-360-19","NDC","facility","outpatient","0.100000","ML","JZ","0.84","0.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN","81000008","CDM","0636","RC","J0613","HCPCS","44567-620-24","NDC","facility","outpatient","0.594594","ML",,"1.66","1.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCIUM GLUCONATE 20MG/ML INTERMITTENT (PEDIATRIC) SH","81000008","CDM","0636","RC","J0613","HCPCS","44567-621-24","NDC","facility","outpatient","0.500000","ML","JZ","1.54","1.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN","81000008","CDM","0636","RC","J0613","HCPCS","44567-620-24","NDC","facility","outpatient","0.500000","ML","JZ","1.66","1.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALCIUM GLUCONATE 20MG/ML INTERMITTENT (PEDIATRIC) SH","81000008","CDM","0636","RC","J0613","HCPCS","44567-621-24","NDC","facility","outpatient","0.530379","ML",,"1.54","1.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CASPOFUNGIN ACETATE 70 MG IV SOLR","81000008","CDM","0636","RC","J0637","HCPCS","0006-3823-10","NDC","facility","outpatient","0.069615","UN","JZ","146.56","146.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CASPOFUNGIN ACETATE 50 MG IV SOLR","81000008","CDM","0636","RC","J0637","HCPCS","0006-3822-10","NDC","facility","outpatient","0.100000","UN","JZ","202.62","202.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 500 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","71288-164-50","NDC","facility","outpatient","0.100000","UN","PN,JZ","67.23","67.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG/17.5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","71288-163-30","NDC","facility","outpatient","0.155212","UN","PN,JZ","28.33","28.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","71288-162-30","NDC","facility","outpatient","0.242857","UN","PN,JZ","56.52","56.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","67457-530-35","NDC","facility","outpatient","0.151619","UN","PN,JZ","29.86","29.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","67457-529-20","NDC","facility","outpatient","0.231066","UN","PN,JZ","79.39","79.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 100 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","67457-528-10","NDC","facility","outpatient","0.441777","UN","PN,JZ","122.10","122.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 500 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","63323-711-00","NDC","facility","outpatient","0.100000","UN","PN,JZ","67.23","67.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","25021-816-30","NDC","facility","outpatient","0.142115","UN","PN,JZ","77.11","77.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 100 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","25021-814-30","NDC","facility","outpatient","0.429090","UN","PN,JZ","106.66","106.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 50 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","25021-813-10","NDC","facility","outpatient","0.725871","UN","PN,JZ","166.57","166.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 50 MG/5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9555-01","NDC","facility","outpatient","0.440000","UN","PN,JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG/20ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9553-01","NDC","facility","outpatient","0.279911","UN","PN,JZ","45.83","45.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG/17.5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9552-01","NDC","facility","outpatient","0.179146","UN","PN,JZ","28.15","28.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG/17.5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","71288-163-30","NDC","facility","outpatient","3.074160","ML","PN,JW","4.98","4.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","71288-162-30","NDC","facility","outpatient","92.666666","ME","PN,JW","12.38","12.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","67457-530-35","NDC","facility","outpatient","3.183333","ML","PN,JW","5.68","5.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 100 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","67457-528-10","NDC","facility","outpatient","92.666666","ME","PN,JW","22.24","22.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","25021-816-30","NDC","facility","outpatient","2.716666","ML","PN,JW","13.04","13.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 200 MG/20ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9553-01","NDC","facility","outpatient","7.166666","ML","PN,JW","10.16","10.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG/17.5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9552-01","NDC","facility","outpatient","2.810126","ML","PN,JW","5.04","5.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"LEUCOVORIN CALCIUM 350 MG/17.5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","71288-163-30","NDC","facility","outpatient","0.156493","UN","PN","27.79","27.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 200 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","71288-162-30","NDC","facility","outpatient","0.178888","UN","PN","100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 350 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","67457-530-35","NDC","facility","outpatient","0.137406","UN","PN","27.87","27.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 100 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","67457-528-10","NDC","facility","outpatient","0.244000","UN","PN","180","180",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 350 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","25021-816-30","NDC","facility","outpatient","0.137903","UN","PN","75.30","75.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 50 MG IJ SOLR","81000008","CDM","0636","RC","J0640","HCPCS","25021-813-10","NDC","facility","outpatient","50.000000","ME","PN","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 50 MG/5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9555-01","NDC","facility","outpatient","23.000000","ME","PN","263.94","263.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 200 MG/20ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9553-01","NDC","facility","outpatient","0.237000","UN","PN","47.05","47.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 350 MG/17.5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9552-01","NDC","facility","outpatient","0.137256","UN","PN","27.91","27.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUCOVORIN CALCIUM 350 MG/17.5ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J0640","HCPCS","0143-9552-01","NDC","facility","outpatient","0.134692","UN","JZ","27.32","27.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOTHYROXINE SODIUM 200 MCG IV SOLR","81000008","CDM","0636","RC","J0651","HCPCS","63323-647-10","NDC","facility","outpatient","0.050000","UN","JZ","63.35","63.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1159-01","NDC","facility","outpatient","0.200000","ML",,"1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","63323-466-37","NDC","facility","outpatient","0.066666","ML","JZ","0.25","0.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","59923-718-05","NDC","facility","outpatient","0.100000","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","55150-169-10","NDC","facility","outpatient","0.122222","ML","JZ","0.64","0.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-9046-01","NDC","facility","outpatient","0.100000","ML","JZ","0.72","0.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-3613-01","NDC","facility","outpatient","0.074772","ML","JZ","4.09","4.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1752-50","NDC","facility","outpatient","0.200000","ML","JZ","0.40","0.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1165-02","NDC","facility","outpatient","0.066666","ML","JZ","0.17","0.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1165-01","NDC","facility","outpatient","0.083669","ML","JZ","0.42","0.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1163-01","NDC","facility","outpatient","0.100000","ML","JZ","0.15","0.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1162-02","NDC","facility","outpatient","0.100000","ML","JZ","0.25","0.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1162-01","NDC","facility","outpatient","0.101492","ML","JZ","0.67","0.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL 0.25 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1160-01","NDC","facility","outpatient","0.200000","ML","JZ","0.61","0.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1159-02","NDC","facility","outpatient","0.288068","ML","JZ","0.78","0.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1159-01","NDC","facility","outpatient","0.349584","ML","JZ","2.14","2.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL 0.25 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1160-01","NDC","facility","outpatient","0.280932","ML",,"1.25","1.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1162-01","NDC","facility","outpatient","0.040000","ML",,"0.75","0.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1163-01","NDC","facility","outpatient","0.148797","ML",,"0.15","0.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1162-02","NDC","facility","outpatient","0.160240","ML",,"0.25","0.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","81483-0004-0","NDC","facility","outpatient","0.100000","ML",,"0.75","0.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","55150-169-10","NDC","facility","outpatient","0.130000","ML",,"0.75","0.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-9046-01","NDC","facility","outpatient","0.145384","ML",,"0.43","0.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE-EPINEPHRINE 0.25% -1:200000 IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1752-50","NDC","facility","outpatient","0.261643","ML",,"0.40","0.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0636","RC","J0665","HCPCS","0409-1165-02","NDC","facility","outpatient","0.078787","ML",,"0.15","0.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEPIVACAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J0670","HCPCS","63323-260-37","NDC","facility","outpatient","10.000000","ML",,"27.37","27.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0688","HCPCS","0143-9924-90","NDC","facility","outpatient","0.656250","UN",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN 1,000 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0688","HCPCS","0143-9262-25","NDC","facility","outpatient","0.500000","UN",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0688","HCPCS","0143-9924-90","NDC","facility","outpatient","0.730769","UN","JZ","19.66","19.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN 1,000 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0688","HCPCS","0143-9262-25","NDC","facility","outpatient","0.500000","UN","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0688","HCPCS","0143-9139-01","NDC","facility","outpatient","0.250000","UN","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0690","HCPCS","60505-6231-5","NDC","facility","outpatient","0.950000","UN","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN 2,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0690","HCPCS","60505-6231-0","NDC","facility","outpatient","25.000000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0690","HCPCS","0781-3451-96","NDC","facility","outpatient","541.182481","ME","JZ","26.52","26.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-%(50ML) IV SOLR","81000008","CDM","0636","RC","J0690","HCPCS","0264-3105-11","NDC","facility","outpatient","0.433673","UN","JZ","31.00","31.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFAZOLIN 500 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0690","HCPCS","0781-3450-95","NDC","facility","outpatient","49.354838","ML",,"64.8","64.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN 1,000 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0690","HCPCS","99999-0011-25","NDC","facility","outpatient","26.344399","ML",,"27.10","27.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFAZOLIN SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0690","HCPCS","0781-3451-96","NDC","facility","outpatient","544.026219","ME",,"26.84","26.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME 1000MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0692","HCPCS","60505-6146-0","NDC","facility","outpatient","0.596153","UN",,"71.16","71.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0692","HCPCS","60505-6147-0","NDC","facility","outpatient","0.277131","UN",,"65.58","65.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0692","HCPCS","60505-6147-4","NDC","facility","outpatient","0.250000","UN",,"65.58","65.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0692","HCPCS","60505-6147-0","NDC","facility","outpatient","0.365384","UN","JZ","65.58","65.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFEPIME 2000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0692","HCPCS","60505-6147-4","NDC","facility","outpatient","0.250000","UN","JZ","65.58","65.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFEPIME 1000MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0692","HCPCS","60505-6146-0","NDC","facility","outpatient","0.243555","UN","JZ","71.16","71.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFOXITIN (MEFOXIN) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0694","HCPCS","25021-110-20","NDC","facility","outpatient","0.500000","UN",,"42","42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN (MEFOXIN) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0694","HCPCS","44567-246-25","NDC","facility","outpatient","1.500000","UN",,"83.79","83.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFOXITIN (MEFOXIN) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0694","HCPCS","0143-9877-25","NDC","facility","outpatient","1.222222","GM","JZ","81.84","81.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE SODIUM 2 G IJ SOLR","81000008","CDM","0636","RC","J0696","HCPCS","44567-702-25","NDC","facility","outpatient","1.125000","UN","JZ","9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE SODIUM 2 G IJ SOLR","81000008","CDM","0636","RC","J0696","HCPCS","60505-6149-4","NDC","facility","outpatient","0.125000","UN","JZ","74.19","74.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0781-3209-95","NDC","facility","outpatient","0.153368","UN","JZ","74.27","74.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0143-9856-25","NDC","facility","outpatient","0.149280","UN",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 1000 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0409-7332-01","NDC","facility","outpatient","0.405172","UN",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE 1GM/50ML D5W (ADV)","81000008","CDM","0636","RC","J0696","HCPCS","0409-7333-04","NDC","facility","outpatient","12.500000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0409-7335-03","NDC","facility","outpatient","0.138745","UN",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE SODIUM 250 MG IJ SOLR","81000008","CDM","0636","RC","J0696","HCPCS","0409-7337-01","NDC","facility","outpatient","0.992444","UN",,"44.37","44.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0696","HCPCS","0781-3208-95","NDC","facility","outpatient","464.285714","ME",,"74.75","74.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0781-3209-95","NDC","facility","outpatient","0.250000","UN",,"74.27","74.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0696","HCPCS","0781-3208-95","NDC","facility","outpatient","263.452914","ME","JZ","64.53","64.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 500 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0409-7338-01","NDC","facility","outpatient","0.690196","UN","JZ","36.32","36.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0409-7335-03","NDC","facility","outpatient","0.170020","UN","JZ","9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0143-9856-25","NDC","facility","outpatient","0.154842","UN","JZ","9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J0696","HCPCS","0143-9857-25","NDC","facility","outpatient","0.464285","UN","JZ","9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 1000 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0409-7332-01","NDC","facility","outpatient","0.304080","UN","JZ","15.78","15.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTRIAXONE (ROCEPHIN) 1000 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","0781-9328-85","NDC","facility","outpatient","12.500000","ML",,"70.45","70.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE SODIUM 2 G IJ SOLR","81000008","CDM","0636","RC","J0696","HCPCS","44567-702-25","NDC","facility","outpatient","0.180555","UN",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTRIAXONE (ROCEPHIN) 2000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","99999-0011-24","NDC","facility","outpatient","12.500000","ML",,"74.27","74.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZZ CEFTRIAXONE (ROCEPHIN) 1 GM (MINIBAG)","81000008","CDM","0636","RC","J0696","HCPCS","99999-0001-31","NDC","facility","outpatient","250.000000","ME",,"74.75","74.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP","81000008","CDM","0636","RC","J0702","HCPCS","0517-0720-01","NDC","facility","outpatient","1.285714","ML",,"92.46","92.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP","81000008","CDM","0636","RC","J0702","HCPCS","78206-118-01","NDC","facility","outpatient","1.470588","ML",,"61.11","61.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTAROLINE FOSAMIL 600 MG IV SOLR","81000008","CDM","0636","RC","J0712","HCPCS","0456-0600-10","NDC","facility","outpatient","0.016666","UN",,"23.35","23.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTAZIDIME (FORTAZ) 2000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J0713","HCPCS","44567-236-10","NDC","facility","outpatient","0.250000","UN",,"21","21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CEFTAZIDIME (FORTAZ) 1000MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J0713","HCPCS","44567-235-25","NDC","facility","outpatient","0.128800","UN","JZ","53.54","53.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTAZIDIME 1 G IJ SOLR","81000008","CDM","0636","RC","J0713","HCPCS","25021-127-20","NDC","facility","outpatient","0.002000","GM","JZ","10.06","10.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR","81000008","CDM","0636","RC","J0714","HCPCS","0456-2700-10","NDC","facility","outpatient","0.250000","UN",,"573.20","573.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","81000008","CDM","0636","RC","J0736","HCPCS","0781-3289-09","NDC","facility","outpatient","25.000000","ML","JZ","51.98","51.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE 600 MG/4ML IJ SOLN","81000008","CDM","0636","RC","J0736","HCPCS","67457-815-04","NDC","facility","outpatient","2.000000","ML","JZ","30.88","30.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE 600 MG/4ML IJ SOLN","81000008","CDM","0636","RC","J0736","HCPCS","67457-815-04","NDC","facility","outpatient","2.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN","81000008","CDM","0636","RC","J0737","HCPCS","0338-3410-24","NDC","facility","outpatient","50.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","81000008","CDM","0636","RC","J0737","HCPCS","0338-3612-24","NDC","facility","outpatient","25.000000","ML","JZ","44.8","44.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN","81000008","CDM","0636","RC","J0737","HCPCS","0338-3814-24","NDC","facility","outpatient","19.972451","ML","JZ","36.52","36.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","81000008","CDM","0636","RC","J0737","HCPCS","43066-993-24","NDC","facility","outpatient","25.000000","ML","JZ","44.8","44.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN","81000008","CDM","0636","RC","J0737","HCPCS","0338-3410-24","NDC","facility","outpatient","53.833333","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 400MG/200ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0636","RC","J0744","HCPCS","0409-3300-01","NDC","facility","outpatient","100.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 400MG/200ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0636","RC","J0744","HCPCS","0409-4777-02","NDC","facility","outpatient","132.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 200MG/100ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0636","RC","J0744","HCPCS","0409-4777-23","NDC","facility","outpatient","100.000000","ML",,"37.19","37.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CIPROFLOXACIN 400MG/200ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0636","RC","J0744","HCPCS","25021-114-87","NDC","facility","outpatient","123.809523","ML",,"39.55","39.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS","81000008","CDM","0636","RC","J0750","HCPCS","60687-719-95","NDC","facility","outpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J0780","HCPCS","25021-790-02","NDC","facility","outpatient","2.662068","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J0780","HCPCS","0713-0351-25","NDC","facility","outpatient","1.666666","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J0780","HCPCS","23155-294-41","NDC","facility","outpatient","3.893617","ML",,"76.2","76.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J0780","HCPCS","23155-294-42","NDC","facility","outpatient","1.937500","ML",,"75.52","75.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DALBAVANCIN HCL 500 MG/25ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J0875","HCPCS","57970-100-01","NDC","facility","outpatient","0.010000","UN","JZ","33.30","33.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 350 MG IV SOLR","81000008","CDM","0636","RC","J0878","HCPCS","16729-434-05","NDC","facility","outpatient","0.002857","UN","JZ","4.63","4.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 350 MG IV SOLR","81000008","CDM","0636","RC","J0878","HCPCS","16729-434-45","NDC","facility","outpatient","0.002857","UN","JZ","4.08","4.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 500 MG IV SOLR","81000008","CDM","0636","RC","J0878","HCPCS","16729-435-05","NDC","facility","outpatient","0.002000","UN","JZ","5.13","5.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 500 MG IV SOLR","81000008","CDM","0636","RC","J0878","HCPCS","60505-6229-4","NDC","facility","outpatient","0.002000","UN","JZ","4.48","4.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 350 MG IV SOLR","81000008","CDM","0636","RC","J0878","HCPCS","70594-053-01","NDC","facility","outpatient","0.002857","UN","JZ","0.89","0.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DAPTOMYCIN 500 MG IV SOLR","81000008","CDM","0636","RC","J0878","HCPCS","71288-016-15","NDC","facility","outpatient","0.003711","UN","JZ","0.50","0.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DARBEPOETIN ALFA 100 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J0881","HCPCS","55513-005-04","NDC","facility","outpatient","0.010000","ML","PN,JZ","27.86","27.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DARBEPOETIN ALFA 200 MCG/0.4ML IJ SOSY","81000008","CDM","0636","RC","J0881","HCPCS","55513-028-01","NDC","facility","outpatient","0.003333","ML","PN,JZ","30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DARBEPOETIN ALFA 100 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J0881","HCPCS","55513-005-04","NDC","facility","outpatient","0.010000","ML","PN,JZ,EC","27.86","27.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy"
"DARBEPOETIN ALFA 200 MCG/0.4ML IJ SOSY","81000008","CDM","0636","RC","J0881","HCPCS","55513-028-01","NDC","facility","outpatient","0.002000","ML","PN,JZ,EC","30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy"
"DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY","81000008","CDM","0636","RC","J0882","HCPCS","55513-023-04","NDC","facility","outpatient","0.005000","ML","PN,JZ","41.67","41.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DECITABINE 50 MG IV SOLR","81000008","CDM","0636","RC","J0894","HCPCS","55111-556-10","NDC","facility","outpatient","0.019900","UN","PN","93.13","93.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DECITABINE 50 MG IV SOLR","81000008","CDM","0636","RC","J0894","HCPCS","55111-556-10","NDC","facility","outpatient","1.020000","ME","PN,JW","14.69","14.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DECITABINE 50 MG IV SOLR","81000008","CDM","0636","RC","J0894","HCPCS","55111-556-10","NDC","facility","outpatient","0.019900","UN","PN,JZ","93.13","93.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DENOSUMAB 60 MG/ML SC SOSY","81000008","CDM","0636","RC","J0897","HCPCS","55513-710-01","NDC","facility","outpatient","0.016666","ML","PN,JZ","125.00","125.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DENOSUMAB 120 MG/1.7ML SC SOLN","81000008","CDM","0636","RC","J0897","HCPCS","55513-730-01","NDC","facility","outpatient","0.017072","ML","PN,JZ","87.5","87.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP","81000008","CDM","0636","RC","J1010","HCPCS","0009-3475-03","NDC","facility","outpatient","0.016847","ML","JZ","2.06","2.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP","81000008","CDM","0636","RC","J1010","HCPCS","70121-1574-5","NDC","facility","outpatient","0.020000","ML",,"1.70","1.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP","81000008","CDM","0636","RC","J1030","HCPCS","0703-0031-04","NDC","facility","outpatient","5.000000","ML","JZ","73.08","73.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP","81000008","CDM","0636","RC","J1040","HCPCS","0009-3475-03","NDC","facility","outpatient","1.000000","ML","JZ","165.68","165.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP","81000008","CDM","0636","RC","J1040","HCPCS","70121-1574-5","NDC","facility","outpatient","1.000000","ML",,"137.06","137.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP","81000008","CDM","0636","RC","J1050","HCPCS","55150-329-01","NDC","facility","outpatient","0.006666","ML",,"1.91","1.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP","81000008","CDM","0636","RC","J1050","HCPCS","67457-887-01","NDC","facility","outpatient","0.006666","ML",,"1.79","1.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","63323-165-30","NDC","facility","outpatient","0.248148","ML","JZ","5.56","5.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","63323-506-01","NDC","facility","outpatient","0.160606","ML","JZ","7.95","7.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-421-30","NDC","facility","outpatient","0.250000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-422-54","NDC","facility","outpatient","9.250000","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-423-12","NDC","facility","outpatient","0.282411","ML","JZ","8.33","8.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","70069-021-25","NDC","facility","outpatient","0.200000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","63323-165-01","NDC","facility","outpatient","0.280923","ML","JZ","14.93","14.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SOD PHOS 4 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J1100","HCPCS","0641-6146-25","NDC","facility","outpatient","0.250000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","63323-165-01","NDC","facility","outpatient","0.265606","ML",,"16.66","16.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","63323-165-05","NDC","facility","outpatient","0.242655","ML",,"5.48","5.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","63323-165-30","NDC","facility","outpatient","0.250000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-421-30","NDC","facility","outpatient","0.250000","ML",,"4.17","4.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","0641-0367-25","NDC","facility","outpatient","0.100000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-422-54","NDC","facility","outpatient","0.268341","ML",,"6.4","6.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-423-12","NDC","facility","outpatient","0.280900","ML",,"9.73","9.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SOD PHOS 4 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J1100","HCPCS","55150-239-30","NDC","facility","outpatient","0.262351","ML","PN","7.13","7.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","70069-021-25","NDC","facility","outpatient","2.531250","ML",,"6.82","6.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","63323-165-01","NDC","facility","outpatient","0.250000","ML","PN","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","63323-165-05","NDC","facility","outpatient","0.250000","ML","PN","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-421-30","NDC","facility","outpatient","0.265588","ML","PN","7.21","7.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-422-54","NDC","facility","outpatient","0.264760","ML","PN","7.34","7.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-423-12","NDC","facility","outpatient","0.250000","ML","PN","17.81","17.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-421-30","NDC","facility","outpatient","0.250000","ML","PN,JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1100","HCPCS","67457-423-12","NDC","facility","outpatient","0.250000","ML","PN,JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1110","HCPCS","81284-411-10","NDC","facility","outpatient","1.000000","ML","JZ","538.69","538.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ACETAZOLAMIDE SODIUM 500 MG IJ SOLR","81000008","CDM","0636","RC","J1120","HCPCS","0143-9503-01","NDC","facility","outpatient","0.900000","UN",,"184.63","184.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETAZOLAMIDE SODIUM 500 MG IJ SOLR","81000008","CDM","0636","RC","J1120","HCPCS","39822-0190-1","NDC","facility","outpatient","1.000000","UN",,"209.17","209.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1160","HCPCS","0641-1410-35","NDC","facility","outpatient","1.782608","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIGOXIN IMMUNE FAB 40 MG IV SOLR","81000008","CDM","0636","RC","J1162","HCPCS","50633-120-11","NDC","facility","outpatient","1.000000","UN",,"8278.2","8278.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYTOIN SODIUM 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1165","HCPCS","0641-0493-25","NDC","facility","outpatient","1.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYTOIN SODIUM 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1165","HCPCS","0641-2555-45","NDC","facility","outpatient","3.000000","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYTOIN SODIUM 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1165","HCPCS","42192-614-30","NDC","facility","outpatient","1.000000","ML","JZ","8.37","8.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0409-1283-05","NDC","facility","outpatient","0.627750","ML",,"84.24","84.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0409-1283-31","NDC","facility","outpatient","1.208105","ML",,"87.94","87.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0409-1312-30","NDC","facility","outpatient","0.460000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0409-4264-01","NDC","facility","outpatient","0.613998","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0409-4264-11","NDC","facility","outpatient","0.516666","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0641-6151-25","NDC","facility","outpatient","0.330357","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL PF 50 MG/5ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0703-0113-03","NDC","facility","outpatient","0.375000","ML",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL PF 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","63323-853-25","NDC","facility","outpatient","0.400000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE 1MG/ML IV PCA (NS) (PREMIX) SH","81000008","CDM","0636","RC","J1170","HCPCS","70092-1117-79","NDC","facility","outpatient","3.897058","ML",,"23.80","23.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL-NACL 30-0.9 MG/30ML-% IV SOSY","81000008","CDM","0636","RC","J1170","HCPCS","70092-1293-49","NDC","facility","outpatient","3.750000","ML",,"16.25","16.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE 1MG/ML NS CADD-SOLIS PCA (PREMIX) (PEDIATRIC) SH","81000008","CDM","0636","RC","J1170","HCPCS","70092-1546-35","NDC","facility","outpatient","5.128205","ML",,"13.75","13.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE VARIABLE DOSE INJ","81000008","CDM","0636","RC","J1170","HCPCS","99999-0006-43","NDC","facility","outpatient","0.775000","ME",,"85.39","85.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE 1MG/ML IV PCA (NS) (PREMIX) SH","81000008","CDM","0636","RC","J1170","HCPCS","99999-0026-83","NDC","facility","outpatient","3.750000","ML",,"17.94","17.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0409-1283-05","NDC","facility","outpatient","0.500000","ML","PN","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0409-1283-31","NDC","facility","outpatient","1.000000","ML","PN","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HYDROMORPHONE VARIABLE DOSE INJ","81000008","CDM","0636","RC","J1170","HCPCS","99999-0006-43","NDC","facility","outpatient","0.263636","ME","PN","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HYDROMORPHONE HCL 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1170","HCPCS","0409-3365-01","NDC","facility","outpatient","0.500117","ML",,"86.51","86.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXRAZOXANE HCL 500 MG IV SOLR","81000008","CDM","0636","RC","J1190","HCPCS","72611-716-01","NDC","facility","outpatient","4.410000","UN","JZ","68.50","68.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1200","HCPCS","72485-101-25","NDC","facility","outpatient","0.591594","ML","PN,JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1200","HCPCS","0641-0376-25","NDC","facility","outpatient","0.547320","ML","PN,JZ","74.07","74.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1200","HCPCS","72485-101-25","NDC","facility","outpatient","0.500000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1200","HCPCS","0641-0376-25","NDC","facility","outpatient","0.829265","ML","JZ","71.72","71.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1200","HCPCS","63323-664-01","NDC","facility","outpatient","0.653614","ML","JZ","73.32","73.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CHLOROTHIAZIDE SODIUM 500 MG IV SOLR","81000008","CDM","0636","RC","J1205","HCPCS","25021-305-20","NDC","facility","outpatient","0.750000","UN","JZ","367.71","367.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1250","HCPCS","0338-1075-02","NDC","facility","outpatient","188.380281","ML",,"156","156",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1250","HCPCS","0409-2347-31","NDC","facility","outpatient","125.000000","ML",,"64.75","64.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1250","HCPCS","0409-2347-32","NDC","facility","outpatient","125.935993","ML",,"34.72","34.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOPAMINE-DEXTROSE 3.2-5 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1265","HCPCS","0409-7810-22","NDC","facility","outpatient","11.460100","ML",,"8.66","8.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOPAMINE-DEXTROSE 3.2-5 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1265","HCPCS","0338-1009-02","NDC","facility","outpatient","12.500000","ML",,"8.31","8.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ECULIZUMAB 300 MG/30ML IV SOLN","81000008","CDM","0636","RC","J1300","HCPCS","25682-001-01","NDC","facility","outpatient","1.000000","ML","PN,JZ","391.38","391.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RAVULIZUMAB-CWVZ 300 MG/3ML IV SOLN","81000008","CDM","0636","RC","J1303","HCPCS","25682-025-01","NDC","facility","outpatient","0.100000","ML","JZ","384.24","384.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RAVULIZUMAB-CWVZ 300 MG/3ML IV SOLN","81000008","CDM","0636","RC","J1303","HCPCS","25682-025-01","NDC","facility","outpatient","0.121428","ML","PN,JZ","323.79","323.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RAVULIZUMAB-CWVZ 1100 MG/11ML IV SOLN","81000008","CDM","0636","RC","J1303","HCPCS","25682-028-01","NDC","facility","outpatient","0.115438","ML","PN,JZ","311.28","311.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERTAPENEM 1,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J1335","HCPCS","55150-282-20","NDC","facility","outpatient","0.532258","UN",,"312","312",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERTAPENEM 1,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J1335","HCPCS","43598-901-11","NDC","facility","outpatient","0.500000","UN",,"390","390",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERTAPENEM 1,000MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J1335","HCPCS","55150-282-20","NDC","facility","outpatient","0.500000","UN","JZ","234","234",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERTAPENEM SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J1335","HCPCS","0006-3843-71","NDC","facility","outpatient","0.500000","UN",,"487.5","487.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR","81000008","CDM","0636","RC","J1364","HCPCS","0409-6482-01","NDC","facility","outpatient","0.925000","UN",,"655.73","655.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ESTROGENS CONJUGATED 25 MG IJ SOLR","81000008","CDM","0636","RC","J1410","HCPCS","0046-0749-05","NDC","facility","outpatient","1.000000","UN","JZ","2208.3","2208.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN","81000008","CDM","0636","RC","J1450","HCPCS","25021-184-82","NDC","facility","outpatient","100.000000","ML",,"75.6","75.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN","81000008","CDM","0636","RC","J1450","HCPCS","25021-184-87","NDC","facility","outpatient","104.081632","ML",,"58.8","58.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN","81000008","CDM","0636","RC","J1450","HCPCS","70655-088-06","NDC","facility","outpatient","100.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN","81000008","CDM","0636","RC","J1450","HCPCS","25021-184-67","NDC","facility","outpatient","112.500000","ML",,"27.36","27.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR","81000008","CDM","0636","RC","J1453","HCPCS","16714-248-01","NDC","facility","outpatient","0.006666","UN","JZ","11.29","11.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR","81000008","CDM","0636","RC","J1453","HCPCS","43598-948-11","NDC","facility","outpatient","0.091111","UN","JZ","0.21","0.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J1453","HCPCS","71839-104-01","NDC","facility","outpatient","0.020000","UN","JZ","12.03","12.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR","81000008","CDM","0636","RC","J1453","HCPCS","16714-248-01","NDC","facility","outpatient","0.006987","UN","PN,JZ","11.20","11.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR","81000008","CDM","0636","RC","J1453","HCPCS","43598-948-11","NDC","facility","outpatient","0.006666","UN","PN,JZ","4.17","4.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR","81000008","CDM","0636","RC","J1453","HCPCS","67457-889-10","NDC","facility","outpatient","0.011111","UN","PN,JZ","10.56","10.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J1453","HCPCS","71839-104-01","NDC","facility","outpatient","0.006722","UN","PN,JZ","11.82","11.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR","81000008","CDM","0636","RC","J1453","HCPCS","72205-054-01","NDC","facility","outpatient","0.006666","UN","PN,JZ","10.71","10.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSAPREPITANT DIMEGLUMINE 150 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J1453","HCPCS","0006-3061-00","NDC","facility","outpatient","0.006666","UN","PN,JZ","13.39","13.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0636","RC","J1459","HCPCS","44206-436-05","NDC","facility","outpatient","5.000000","ML","JZ","316.69","316.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0636","RC","J1459","HCPCS","44206-437-10","NDC","facility","outpatient","5.000000","ML","JZ","315.37","315.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0636","RC","J1459","HCPCS","44206-438-20","NDC","facility","outpatient","7.222222","ML","JZ","322.84","322.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0636","RC","J1459","HCPCS","44206-439-40","NDC","facility","outpatient","5.000000","ML","JZ","298.24","298.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0636","RC","J1459","HCPCS","44206-436-05","NDC","facility","outpatient","13.000000","ML","PN,JZ","27.86","27.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0636","RC","J1459","HCPCS","44206-437-10","NDC","facility","outpatient","5.000000","ML","PN,JZ","108.37","108.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0636","RC","J1459","HCPCS","44206-438-20","NDC","facility","outpatient","5.000000","ML","PN,JZ","316.70","316.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - PRIVIGEN","81000008","CDM","0636","RC","J1459","HCPCS","44206-439-40","NDC","facility","outpatient","5.000000","ML","PN,JZ","228.30","228.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - GAMUNEX-C","81000008","CDM","0636","RC","J1561","HCPCS","13533-800-71","NDC","facility","outpatient","5.000000","ML","JZ","251.38","251.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - OCTAGAM","81000008","CDM","0636","RC","J1568","HCPCS","0069-6339-02","NDC","facility","outpatient","5.000000","ML","PN,JZ","349.66","349.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IMMUNE GLOBULIN (HUMAN) 10% IV SOLN - OCTAGAM","81000008","CDM","0636","RC","J1568","HCPCS","0069-6237-02","NDC","facility","outpatient","5.000000","ML","PN,JZ","349.66","349.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GANCICLOVIR SODIUM 500 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J1570","HCPCS","70436-089-55","NDC","facility","outpatient","0.040000","UN","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPATITIS B IMMUNE GLOBULIN IV SOLN SH","81000008","CDM","0636","RC","J1573","HCPCS","70257-051-51","NDC","facility","outpatient","0.500000","ML","PN,JZ","44.50","44.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GENTAMICIN SULFATE 40 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1580","HCPCS","0409-1207-03","NDC","facility","outpatient","2.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GENTAMICIN SULFATE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1580","HCPCS","63323-173-02","NDC","facility","outpatient","6.583333","ML","JZ","143.47","143.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GENTAMICIN IN SALINE 0.8-0.9 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1580","HCPCS","0338-0503-48","NDC","facility","outpatient","97.580645","ML",,"42.24","42.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN IN SALINE 1-0.9 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1580","HCPCS","0338-0505-48","NDC","facility","outpatient","50.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN SULFATE 40 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1580","HCPCS","63323-010-02","NDC","facility","outpatient","1.764583","ML",,"69.90","69.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GENTAMICIN SULFATE 40 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1580","HCPCS","63323-010-20","NDC","facility","outpatient","1.856666","ML",,"27.32","27.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1596","HCPCS","43547-543-25","NDC","facility","outpatient","0.807692","ML","JZ","40.38","40.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1596","HCPCS","43547-543-01","NDC","facility","outpatient","0.500000","ML","JZ","46.88","46.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1596","HCPCS","0517-4601-25","NDC","facility","outpatient","0.532991","ML","JZ","54.46","54.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL (RDNA) 1 MG IJ SOLR","81000008","CDM","0636","RC","J1610","HCPCS","0169-7065-15","NDC","facility","outpatient","68.750000","ME","JZ","1192.8","1192.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL (RDNA) 1 MG IJ SOLR","81000008","CDM","0636","RC","J1610","HCPCS","55390-004-01","NDC","facility","outpatient","0.500000","UN","JZ","669.24","669.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL (RDNA) 1 MG IJ SOLR","81000008","CDM","0636","RC","J1610","HCPCS","0169-7065-15","NDC","facility","outpatient","1.862222","ME",,"975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCAGON EMERGENCY 1 MG IJ KIT","81000008","CDM","0636","RC","J1610","HCPCS","0548-5850-00","NDC","facility","outpatient","1.000000","ME",,"1680","1680",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0636","RC","J1611","HCPCS","63323-593-03","NDC","facility","outpatient","0.947916","UN","JZ","1284.87","1284.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0636","RC","J1611","HCPCS","63323-596-06","NDC","facility","outpatient","1.802631","UN","JZ","931.06","931.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0636","RC","J1611","HCPCS","63323-596-08","NDC","facility","outpatient","1.000000","UN","JZ","975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0636","RC","J1611","HCPCS","63323-596-11","NDC","facility","outpatient","0.990000","UN","JZ","1288.15","1288.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLUCAGON HCL 1 MG IJ SOLR - CONSOLIDATED","81000008","CDM","0636","RC","J1611","HCPCS","63323-596-13","NDC","facility","outpatient","1.147727","UN","JZ","1273.80","1273.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HALOPERIDOL LACTATE 5 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1630","HCPCS","63323-474-01","NDC","facility","outpatient","1.483072","ML",,"69.16","69.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HALOPERIDOL LACTATE 5 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1630","HCPCS","67457-426-12","NDC","facility","outpatient","0.429850","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN NA (PORK) LOCK FLSH PF 10 UNIT/ML IV SOLN","81000008","CDM","0636","RC","J1642","HCPCS","64253-222-35","NDC","facility","outpatient","1.000000","ML",,"3.44","3.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN","81000008","CDM","0636","RC","J1642","HCPCS","64253-333-35","NDC","facility","outpatient","0.272839","ML",,"0.35","0.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN","81000008","CDM","0636","RC","J1642","HCPCS","64253-333-35","NDC","facility","outpatient","0.100000","ML","PN","0.35","0.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN","81000008","CDM","0636","RC","J1642","HCPCS","8290-306424","NDC","facility","outpatient","0.100000","ML","PN,JZ","0.47","0.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","0409-2723-01","NDC","facility","outpatient","0.199694","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN (PORCINE) 2 UNITS/ML 0.9% NACL LINE PATENCY DRIP (PREMIX) SH","81000008","CDM","0636","RC","J1644","HCPCS","0409-7620-03","NDC","facility","outpatient","2944.444444","ML","JZ","56.23","56.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","0641-0400-12","NDC","facility","outpatient","0.305263","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","63323-276-02","NDC","facility","outpatient","1.028571","ML","JZ","52.89","52.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","71288-403-02","NDC","facility","outpatient","0.240368","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","0409-2720-02","NDC","facility","outpatient","1.000000","ML",,"3","3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN","81000008","CDM","0636","RC","J1644","HCPCS","0409-7650-30","NDC","facility","outpatient","13.555555","ML",,"3.71","3.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN","81000008","CDM","0636","RC","J1644","HCPCS","0409-7650-62","NDC","facility","outpatient","28.946988","ML",,"13.54","13.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","25021-402-01","NDC","facility","outpatient","0.193197","ML",,"16.67","16.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","63323-262-01","NDC","facility","outpatient","0.300393","ML",,"14.84","14.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN","81000008","CDM","0636","RC","J1644","HCPCS","63323-517-01","NDC","facility","outpatient","12.364532","ML",,"3.11","3.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","63323-540-01","NDC","facility","outpatient","1.646153","ML",,"35.87","35.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","63323-540-03","NDC","facility","outpatient","2.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","63323-540-11","NDC","facility","outpatient","1.095485","ML",,"8.64","8.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN TOPICAL SCRUB FOR VENOUS CONGESTION SH","81000008","CDM","0636","RC","J1644","HCPCS","63323-540-15","NDC","facility","outpatient","1.000000","ML",,"6.10","6.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN SODIUM (PORCINE) 10000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J1644","HCPCS","63323-542-01","NDC","facility","outpatient","0.100000","ML",,"6.41","6.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN 30,000 UNIT/1000 ML 0.9% NACL (CELL SAVER PREMIX)","81000008","CDM","0636","RC","J1644","HCPCS","70092-1281-08","NDC","facility","outpatient","33.333333","ML",,"9.1","9.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 2000-0.9 UNIT/L-% IV SOLN","81000008","CDM","0636","RC","J1644","HCPCS","0409-7620-59","NDC","facility","outpatient","3166.666666","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 100 MG/ML IJ SOSY","81000008","CDM","0636","RC","J1650","HCPCS","0075-0623-00","NDC","facility","outpatient","0.091000","ML",,"18.98","18.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","0781-3246-02","NDC","facility","outpatient","0.218518","ML",,"19.54","19.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","63323-535-87","NDC","facility","outpatient","0.100000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","63323-559-93","NDC","facility","outpatient","0.500000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","63323-564-97","NDC","facility","outpatient","0.141379","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","63323-566-21","NDC","facility","outpatient","0.100000","ML",,"7.51","7.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","63323-584-99","NDC","facility","outpatient","0.090000","ML",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","63323-586-21","NDC","facility","outpatient","0.100000","ML",,"7.83","7.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","71288-433-82","NDC","facility","outpatient","0.126086","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY","81000008","CDM","0636","RC","J1650","HCPCS","0075-0620-40","NDC","facility","outpatient","0.300000","ML","JZ","8.93","8.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY","81000008","CDM","0636","RC","J1650","HCPCS","0075-0622-80","NDC","facility","outpatient","0.093333","ML","JZ","19.47","19.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","63323-564-97","NDC","facility","outpatient","0.100000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN IPS SH","81000008","CDM","0636","RC","J1650","HCPCS","63323-566-21","NDC","facility","outpatient","0.500000","ML","JZ","12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY","81000008","CDM","0636","RC","J1670","HCPCS","13533-634-02","NDC","facility","outpatient","1.000000","ML","JZ","2337","2337",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR","81000008","CDM","0636","RC","J1720","HCPCS","0009-0011-04","NDC","facility","outpatient","0.397442","UN","JZ","88.60","88.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLIXIMAB 100 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J1745","HCPCS","57894-030-01","NDC","facility","outpatient","0.098924","UN","PN","284.81","284.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"INFLIXIMAB 100 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J1745","HCPCS","57894-030-01","NDC","facility","outpatient","1.077272","ML","PN,JW","150.97","150.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"INFLIXIMAB 100 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J1745","HCPCS","57894-030-01","NDC","facility","outpatient","0.124333","UN","PN,JZ","252.86","252.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","49230-534-10","NDC","facility","outpatient","0.050000","ML","JZ","2.81","2.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","0517-2340-01","NDC","facility","outpatient","0.050000","ML",,"3.70","3.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","0517-2340-10","NDC","facility","outpatient","0.055676","ML",,"3.19","3.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","0517-2340-25","NDC","facility","outpatient","0.050000","ML",,"4.11","4.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","49230-534-10","NDC","facility","outpatient","0.050000","ML",,"2.81","2.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","0517-2310-05","NDC","facility","outpatient","0.050000","ML","PN","4.77","4.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","0517-2340-01","NDC","facility","outpatient","0.056685","ML","PN","3.77","3.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","0517-2340-10","NDC","facility","outpatient","0.061575","ML","PN","4.54","4.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IRON SUCROSE 20 MG/ML IV SOLN","81000008","CDM","0636","RC","J1756","HCPCS","0517-2340-25","NDC","facility","outpatient","0.055555","ML","PN","4.78","4.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ESMOLOL HCL-SODIUM CHLORIDE 2000 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1805","HCPCS","10019-075-87","NDC","facility","outpatient","1.500000","ML","JZ","12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ESMOLOL HCL 100 MG/10ML IV SOLN","81000008","CDM","0636","RC","J1805","HCPCS","10019-120-01","NDC","facility","outpatient","1.216919","ML","JZ","13.47","13.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ESMOLOL HCL-SODIUM CHLORIDE 2000 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1805","HCPCS","25021-309-82","NDC","facility","outpatient","2.500000","ML","JZ","4.88","4.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INSULIN REG HUMAN 100 UNITS/100ML NS IV DRIP GEN MED (PREMIX) SH","81000008","CDM","0636","RC","J1815","HCPCS","0338-0126-12","NDC","facility","outpatient","5.000000","ML",,"0.5","0.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","0338-1055-48","NDC","facility","outpatient","2.965517","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","0409-0152-24","NDC","facility","outpatient","2.626198","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","0409-7811-24","NDC","facility","outpatient","2.267402","ML","JZ","1.47","1.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","25021-131-82","NDC","facility","outpatient","2.000000","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","47335-993-01","NDC","facility","outpatient","6.000000","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","80830-2465-1","NDC","facility","outpatient","3.600000","ML","JZ","1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","0338-1055-48","NDC","facility","outpatient","1.987804","ML",,"1.85","1.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","0409-0152-24","NDC","facility","outpatient","7.163793","ML",,"1.62","1.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","0409-7811-24","NDC","facility","outpatient","2.000000","ML",,"1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1836","HCPCS","47335-993-01","NDC","facility","outpatient","10.000000","ML",,"3","3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1885","HCPCS","63323-162-01","NDC","facility","outpatient","2.833333","ML",,"40.38","40.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1885","HCPCS","0338-0072-25","NDC","facility","outpatient","0.605000","ML","JZ","36.96","36.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN","81000008","CDM","0636","RC","J1885","HCPCS","0409-3796-01","NDC","facility","outpatient","0.500000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1885","HCPCS","62332-600-01","NDC","facility","outpatient","0.528985","ML","JZ","45","45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1885","HCPCS","63323-161-01","NDC","facility","outpatient","1.165206","ML","JZ","72.23","72.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1885","HCPCS","63323-162-01","NDC","facility","outpatient","0.584204","ML","JZ","40.87","40.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN","81000008","CDM","0636","RC","J1885","HCPCS","63323-162-02","NDC","facility","outpatient","0.455130","ML","JZ","53.48","53.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1885","HCPCS","72266-118-25","NDC","facility","outpatient","0.555555","ML","JZ","39.84","39.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1885","HCPCS","72611-722-25","NDC","facility","outpatient","0.500000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"KETOROLAC VARIABLE DOSE INJ","81000008","CDM","0636","RC","J1885","HCPCS","99999-0006-45","NDC","facility","outpatient","21.985294","ME",,"69.41","69.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J1920","HCPCS","0409-2339-34","NDC","facility","outpatient","0.972222","ML","JZ","35.81","35.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J1920","HCPCS","0409-2339-34","NDC","facility","outpatient","1.225490","ML",,"39.19","39.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J1920","HCPCS","36000-322-01","NDC","facility","outpatient","1.000000","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J1920","HCPCS","69374-946-34","NDC","facility","outpatient","0.923076","ML",,"42.86","42.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LANREOTIDE ACETATE 120 MG/0.5ML SC SOLN","81000008","CDM","0636","RC","J1930","HCPCS","15054-1120-4","NDC","facility","outpatient","0.004166","ML","PN,JZ","143.43","143.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LANREOTIDE ACETATE 120 MG/0.5ML SC SOLN","81000008","CDM","0636","RC","J1932","HCPCS","69097-870-67","NDC","facility","outpatient","0.004166","ML","PN,JZ","133.39","133.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1939","HCPCS","70860-405-41","NDC","facility","outpatient","2.000000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1939","HCPCS","72205-101-01","NDC","facility","outpatient","2.640000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1939","HCPCS","68462-470-54","NDC","facility","outpatient","2.170666","ML",,"4.14","4.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1939","HCPCS","65219-572-10","NDC","facility","outpatient","2.000000","ML",,"6.43","6.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1939","HCPCS","0641-6008-10","NDC","facility","outpatient","2.122699","ML",,"19.14","19.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1939","HCPCS","0409-1412-04","NDC","facility","outpatient","2.000000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1939","HCPCS","0641-6007-10","NDC","facility","outpatient","2.047169","ML",,"5.65","5.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUMETANIDE 0.25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1939","HCPCS","65219-570-01","NDC","facility","outpatient","2.000000","ML",,"28.12","28.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","0409-6102-02","NDC","facility","outpatient","3.083414","ML","JZ","66.64","66.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","0409-6102-04","NDC","facility","outpatient","2.597244","ML","JZ","31.60","31.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","0409-6102-10","NDC","facility","outpatient","2.102214","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","16729-501-43","NDC","facility","outpatient","2.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","23155-473-41","NDC","facility","outpatient","2.470588","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","36000-283-25","NDC","facility","outpatient","2.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","63323-280-02","NDC","facility","outpatient","2.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","63323-280-04","NDC","facility","outpatient","2.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","70860-302-04","NDC","facility","outpatient","2.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","71288-203-05","NDC","facility","outpatient","2.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FUROSEMIDE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J1940","HCPCS","0409-6102-04","NDC","facility","outpatient","1.000000","ML","PN,JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUPROLIDE ACETATE 3.75 MG IM KIT","81000008","CDM","0636","RC","J1950","HCPCS","0074-3641-03","NDC","facility","outpatient","1.148148","UN","PN,JZ","7500","7500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT","81000008","CDM","0636","RC","J1950","HCPCS","0074-3663-03","NDC","facility","outpatient","0.416666","UN","PN,JZ","4500","4500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM 100MG/ML IV SYRINGE LOADING DOSE SH","81000008","CDM","0636","RC","J1953","HCPCS","0409-1886-02","NDC","facility","outpatient","0.109817","ML",,"0.61","0.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1953","HCPCS","70860-603-82","NDC","facility","outpatient","1.500000","ML","JZ","4.37","4.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1953","HCPCS","67457-266-10","NDC","facility","outpatient","8.666666","ML","JZ","1.48","1.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1953","HCPCS","67457-265-10","NDC","facility","outpatient","1.000000","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM 100MG/ML IV SYRINGE LOADING DOSE SH","81000008","CDM","0636","RC","J1953","HCPCS","0409-1886-02","NDC","facility","outpatient","0.107907","ML","JZ","0.76","0.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1953","HCPCS","43598-635-10","NDC","facility","outpatient","2.184615","ML","JZ","3.11","3.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1953","HCPCS","43598-636-10","NDC","facility","outpatient","1.064516","ML","JZ","2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM 15MG/ML IN NACL IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0636","RC","J1953","HCPCS","43598-637-10","NDC","facility","outpatient","0.920634","ML","JZ","2.08","2.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1953","HCPCS","55150-247-47","NDC","facility","outpatient","1.000000","ML","JZ","3.51","3.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J1953","HCPCS","67457-255-10","NDC","facility","outpatient","2.000000","ML","JZ","2.35","2.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOFLOXACIN 750MG/150ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0636","RC","J1956","HCPCS","0143-9720-24","NDC","facility","outpatient","64.285714","ML","JZ","25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOFLOXACIN 500MG/100ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0636","RC","J1956","HCPCS","0143-9721-24","NDC","facility","outpatient","50.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVOFLOXACIN 750MG/150ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0636","RC","J1956","HCPCS","0143-9720-24","NDC","facility","outpatient","50.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOFLOXACIN 750MG/150ML D5W (PREMIX) CUSTOM-CREATE","81000008","CDM","0636","RC","J1956","HCPCS","25021-132-83","NDC","facility","outpatient","50.000000","ML",,"30.8","30.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE IN D5W 8-5 MG/ML-% IV SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0338-0411-02","NDC","facility","outpatient","1.195833","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 0.5 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-4275-01","NDC","facility","outpatient","2.000000","ML",,"3","3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-4276-01","NDC","facility","outpatient","12.864864","ML",,"6.5","6.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-4277-01","NDC","facility","outpatient","0.885964","ML",,"1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 4 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-4283-01","NDC","facility","outpatient","0.250000","ML",,"2.26","2.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-4713-02","NDC","facility","outpatient","1.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY","81000008","CDM","0636","RC","J2001","HCPCS","0409-4903-34","NDC","facility","outpatient","0.500000","ML",,"7.18","7.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-2066-05","NDC","facility","outpatient","0.540564","ML","JZ","9.63","9.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-4279-02","NDC","facility","outpatient","1.117647","ML","JZ","3.29","3.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-4282-02","NDC","facility","outpatient","0.645454","ML","JZ","3.34","3.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","55150-161-02","NDC","facility","outpatient","0.223866","ML","JZ","72.11","72.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","55150-162-05","NDC","facility","outpatient","0.206896","ML","JZ","78.24","78.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","55150-163-30","NDC","facility","outpatient","1.000000","ML","JZ","5.83","5.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-201-02","NDC","facility","outpatient","1.114302","ML","JZ","17.06","17.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-492-27","NDC","facility","outpatient","0.369573","ML","JZ","65.30","65.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-492-37","NDC","facility","outpatient","5.000000","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-492-57","NDC","facility","outpatient","1.097033","ML","JZ","18.14","18.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-495-07","NDC","facility","outpatient","0.497368","ML","JZ","4.91","4.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-495-27","NDC","facility","outpatient","0.555757","ML","JZ","14.57","14.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","73293-0001-1","NDC","facility","outpatient","0.223384","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","73293-0001-2","NDC","facility","outpatient","0.236258","ML","JZ","71.28","71.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","55150-161-02","NDC","facility","outpatient","9.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","55150-163-30","NDC","facility","outpatient","0.421153","ML",,"2.77","2.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","55150-162-05","NDC","facility","outpatient","1.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-201-10","NDC","facility","outpatient","1.000000","ML",,"6.40","6.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-202-02","NDC","facility","outpatient","0.629870","ML",,"7.44","7.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-486-17","NDC","facility","outpatient","0.500000","ML",,"0.53","0.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-486-27","NDC","facility","outpatient","0.500000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-492-27","NDC","facility","outpatient","3.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 1.5 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-493-97","NDC","facility","outpatient","0.638157","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-495-27","NDC","facility","outpatient","3.400000","ML",,"12.93","12.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","73293-0001-2","NDC","facility","outpatient","0.900000","ML",,"11.25","11.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","0409-4276-01","NDC","facility","outpatient","1.041411","ML","PN","8.04","8.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-492-27","NDC","facility","outpatient","0.200000","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE HCL 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","55150-161-02","NDC","facility","outpatient","0.485294","ML","PN,JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LIDOCAINE HCL (PF) 1 % IJ SOLN","81000008","CDM","0636","RC","J2001","HCPCS","63323-492-27","NDC","facility","outpatient","0.400366","ML","PN,JZ","72.54","72.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LINEZOLID 600 MG/300ML IV SOLN","81000008","CDM","0636","RC","J2020","HCPCS","0009-5140-04","NDC","facility","outpatient","100.000000","ML",,"124.8","124.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINEZOLID 600 MG/300ML IV SOLN","81000008","CDM","0636","RC","J2020","HCPCS","25021-169-87","NDC","facility","outpatient","100.000000","ML",,"91","91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LINEZOLID 600 MG/300ML IV SOLN","81000008","CDM","0636","RC","J2020","HCPCS","66794-219-63","NDC","facility","outpatient","100.000000","ML",,"53.2","53.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2060","HCPCS","0641-6044-25","NDC","facility","outpatient","0.817168","ML",,"85.06","85.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2060","HCPCS","0641-6048-25","NDC","facility","outpatient","0.700000","ML",,"85.71","85.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2060","HCPCS","0641-6001-25","NDC","facility","outpatient","0.644444","ML",,"96","96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LORAZEPAM 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2060","HCPCS","0409-1985-30","NDC","facility","outpatient","1.102941","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MANNITOL 25 % IV SOLN","81000008","CDM","0636","RC","J2150","HCPCS","63323-024-25","NDC","facility","outpatient","50.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MANNITOL 25 % IV SOLN","81000008","CDM","0636","RC","J2150","HCPCS","0409-4031-01","NDC","facility","outpatient","50.000000","ML","PN","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MEPERIDINE HCL 25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2175","HCPCS","0409-1176-30","NDC","facility","outpatient","0.900000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEPERIDINE HCL 25 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2175","HCPCS","0641-6052-25","NDC","facility","outpatient","0.666666","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEPERIDINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2175","HCPCS","0641-6053-25","NDC","facility","outpatient","0.375000","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEPERIDINE VARIABLE DOSE INJ","81000008","CDM","0636","RC","J2175","HCPCS","99999-0006-48","NDC","facility","outpatient","250.000000","ME",,"187.5","187.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEPERIDINE HCL 50 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2175","HCPCS","0641-6053-25","NDC","facility","outpatient","0.500000","ML","PN","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2185","HCPCS","0409-1391-21","NDC","facility","outpatient","0.100000","UN",,"17.40","17.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2185","HCPCS","0409-3506-01","NDC","facility","outpatient","10.000000","ML",,"22.68","22.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2185","HCPCS","0781-3098-95","NDC","facility","outpatient","0.100000","UN",,"23.68","23.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2185","HCPCS","55150-208-30","NDC","facility","outpatient","0.100000","UN",,"9.24","9.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 500 MG/50ML NS (MINIBAG)","81000008","CDM","0636","RC","J2185","HCPCS","63323-507-20","NDC","facility","outpatient","0.226966","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2185","HCPCS","63323-508-30","NDC","facility","outpatient","0.106596","UN",,"7.38","7.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2185","HCPCS","0409-1391-21","NDC","facility","outpatient","0.100000","UN","JZ","17.40","17.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MEROPENEM 1,000 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2185","HCPCS","63323-508-30","NDC","facility","outpatient","0.153333","UN","JZ","4.96","4.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2210","HCPCS","0517-0740-20","NDC","facility","outpatient","1.129032","ML","JZ","235.98","235.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2210","HCPCS","0517-0740-20","NDC","facility","outpatient","1.000000","ML",,"234.75","234.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MICAFUNGIN 100MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2248","HCPCS","63323-729-01","NDC","facility","outpatient","0.010000","UN",,"11.22","11.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J2250","HCPCS","0409-2305-05","NDC","facility","outpatient","1.460937","ML",,"16.48","16.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J2250","HCPCS","0409-2305-17","NDC","facility","outpatient","1.168765","ML",,"39.77","39.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 5 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J2250","HCPCS","0409-2308-01","NDC","facility","outpatient","0.283269","ML",,"17.73","17.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 5 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J2250","HCPCS","0409-2596-05","NDC","facility","outpatient","0.196610","ML",,"25.93","25.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J2250","HCPCS","0641-6057-10","NDC","facility","outpatient","1.000000","ML",,"33.75","33.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J2250","HCPCS","0641-6057-25","NDC","facility","outpatient","1.140888","ML",,"45.76","45.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J2250","HCPCS","23155-600-41","NDC","facility","outpatient","2.000000","ML",,"45","45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0636","RC","J2250","HCPCS","70092-1030-36","NDC","facility","outpatient","1.000000","ML",,"1.92","1.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL 1 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J2250","HCPCS","0641-6057-25","NDC","facility","outpatient","1.000000","ML","PN","45","45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0636","RC","J2250","HCPCS","44567-611-10","NDC","facility","outpatient","1.000000","ML",,"1.8","1.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0636","RC","J2251","HCPCS","44567-611-10","NDC","facility","outpatient","87.666666","ML",,"1.8","1.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J2270","HCPCS","0409-1890-01","NDC","facility","outpatient","1.655215","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2270","HCPCS","0409-1893-01","NDC","facility","outpatient","0.428571","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2270","HCPCS","0409-3814-12","NDC","facility","outpatient","13.333333","ML",,"102.77","102.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE 4 MG/ML IV SOLN","81000008","CDM","0636","RC","J2270","HCPCS","0641-6125-25","NDC","facility","outpatient","1.359291","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2270","HCPCS","0641-6127-25","NDC","facility","outpatient","0.762637","ML",,"60","60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2270","HCPCS","63323-454-01","NDC","facility","outpatient","2.666666","ML",,"63.69","63.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE-NACL 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0636","RC","J2270","HCPCS","70092-1130-36","NDC","facility","outpatient","10.000000","ML",,"13","13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE-NACL 100-0.9 MG/100ML-% IV SOLN","81000008","CDM","0636","RC","J2270","HCPCS","70092-1380-36","NDC","facility","outpatient","10.000000","ML",,"11.86","11.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE VARIABLE DOSE INJ","81000008","CDM","0636","RC","J2270","HCPCS","99999-0006-49","NDC","facility","outpatient","2.800000","ME",,"75.21","75.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2272","HCPCS","63323-454-01","NDC","facility","outpatient","1.000000","ML","JZ","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MORPHINE SULFATE (PF) 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2272","HCPCS","63323-451-01","NDC","facility","outpatient","0.611363","ML",,"52.22","52.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2272","HCPCS","63323-454-01","NDC","facility","outpatient","1.317518","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MORPHINE SULFATE (PF) 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2272","HCPCS","63323-452-01","NDC","facility","outpatient","1.000000","ML","PN","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MORPHINE SULFATE 2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2272","HCPCS","76045-004-10","NDC","facility","outpatient","1.000000","ML","PN","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2274","HCPCS","0641-6019-10","NDC","facility","outpatient","6.057142","ML",,"112.94","112.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MOXIFLOXACIN HCL 0.3 MG/0.3ML IO SOSY","81000008","CDM","0636","RC","J2280","HCPCS","71266-8613-1","NDC","facility","outpatient","0.312000","ML",,"240.62","240.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MOXIFLOXACIN HCL 0.3 MG/0.3ML IO SOSY","81000008","CDM","0636","RC","J2280","HCPCS","71266-8603-1","NDC","facility","outpatient","0.300000","ML",,"229.26","229.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 100MCG/ML INJ","81000008","CDM","0636","RC","J2305","HCPCS","0338-1047-02","NDC","facility","outpatient","2.000000","ML","GZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary"
"NITROGLYCERIN 100MCG/ML INJ","81000008","CDM","0636","RC","J2305","HCPCS","0338-1047-02","NDC","facility","outpatient","2.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NITROGLYCERIN 200MCG/ML INJ SH","81000008","CDM","0636","RC","J2305","HCPCS","0338-1049-02","NDC","facility","outpatient","1.428571","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NITROGLYCERIN 5 MG/ML IV SOLN","81000008","CDM","0636","RC","J2305","HCPCS","0517-4810-25","NDC","facility","outpatient","0.998503","ML","JZ","7.45","7.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NITROGLYCERIN 100MCG/ML INJ","81000008","CDM","0636","RC","J2305","HCPCS","0338-1047-02","NDC","facility","outpatient","2.045197","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 200MCG/ML INJ SH","81000008","CDM","0636","RC","J2305","HCPCS","0338-1049-02","NDC","facility","outpatient","57.916666","ML",,"18.9","18.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NITROGLYCERIN 100MCG/ML INJ","81000008","CDM","0636","RC","J2305","HCPCS","0409-1483-02","NDC","facility","outpatient","16.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0636","RC","J2310","HCPCS","0641-6205-01","NDC","facility","outpatient","1.000000","ML",,"122.85","122.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0636","RC","J2310","HCPCS","55150-345-01","NDC","facility","outpatient","0.983458","ML",,"111.72","111.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 4 MG/10ML IJ SOLN","81000008","CDM","0636","RC","J2310","HCPCS","55150-328-01","NDC","facility","outpatient","2.500000","ML",,"186.88","186.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2310","HCPCS","70069-071-01","NDC","facility","outpatient","1.375000","ML",,"107.92","107.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 4 MG/10ML IJ SOLN","81000008","CDM","0636","RC","J2310","HCPCS","67457-299-10","NDC","facility","outpatient","4.166666","ML",,"178.11","178.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 4 MG/10ML IJ SOLN","81000008","CDM","0636","RC","J2310","HCPCS","55150-328-10","NDC","facility","outpatient","22.500000","ML",,"186.88","186.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2310","HCPCS","36000-308-10","NDC","facility","outpatient","1.456521","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2310","HCPCS","0409-1215-01","NDC","facility","outpatient","2.281250","ML","JZ","176.70","176.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NALOXONE HCL 0.4 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2310","HCPCS","67457-292-02","NDC","facility","outpatient","1.393750","ML","JZ","330.64","330.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NALOXONE HCL 2 MG/2ML IJ SOSY","81000008","CDM","0636","RC","J2310","HCPCS","76329-3369-1","NDC","facility","outpatient","1.015873","ML","JZ","122.12","122.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NUSINERSEN 12 MG/5ML IT SOLN","81000008","CDM","0636","RC","J2326","HCPCS","64406-058-01","NDC","facility","outpatient","0.075000","ML","JZ","1604.89","1604.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","81000008","CDM","0636","RC","J2359","HCPCS","31722-308-01","NDC","facility","outpatient","0.050000","UN","JZ","13.85","13.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OLANZAPINE 10 MG IM SOLR","81000008","CDM","0636","RC","J2359","HCPCS","0002-7597-01","NDC","facility","outpatient","0.050000","UN","JZ","19.76","19.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYLEPHRINE HCL-NACL 50-0.9 MG/250ML-% IV SOLN","81000008","CDM","0636","RC","J2370","HCPCS","70092-9045-05","NDC","facility","outpatient","35.550000","ML",,"90.76","90.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2370","HCPCS","0641-6142-25","NDC","facility","outpatient","0.030000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2371","HCPCS","0641-6142-25","NDC","facility","outpatient","0.002150","ML","JZ","4.43","4.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2371","HCPCS","0641-6142-25","NDC","facility","outpatient","0.002000","ML",,"0.08","0.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2371","HCPCS","0781-3458-95","NDC","facility","outpatient","0.002000","ML",,"0.08","0.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2371","HCPCS","63323-751-00","NDC","facility","outpatient","0.002000","ML",,"0.29","0.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL-NACL 1-0.9 MG/10ML-% IV SOSY","81000008","CDM","0636","RC","J2371","HCPCS","70092-1046-46","NDC","facility","outpatient","0.220263","ML",,"5.60","5.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL-NACL 50-0.9 MG/250ML-% IV SOLN","81000008","CDM","0636","RC","J2371","HCPCS","70092-9045-05","NDC","facility","outpatient","0.125424","ML",,"0.17","0.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENYLEPHRINE HCL-NACL 50-0.9 MG/250ML-% IV SOLN","81000008","CDM","0636","RC","J2371","HCPCS","71266-5250-1","NDC","facility","outpatient","0.118604","ML",,"0.08","0.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROPROCAINE HCL 2 % IJ SOLN","81000008","CDM","0636","RC","J2401","HCPCS","63323-476-37","NDC","facility","outpatient","0.051317","ML",,"0.26","0.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROPROCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0636","RC","J2401","HCPCS","63323-477-27","NDC","facility","outpatient","0.066129","ML",,"0.42","0.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROPROCAINE HCL (PF) 3 % IJ SOLN","81000008","CDM","0636","RC","J2401","HCPCS","63323-478-27","NDC","facility","outpatient","0.033333","ML",,"0.26","0.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CHLOROPROCAINE HCL 2 % IJ SOLN","81000008","CDM","0636","RC","J2401","HCPCS","63323-476-37","NDC","facility","outpatient","0.050000","ML","PN","0.26","0.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CHLOROPROCAINE HCL (PF) 2 % IJ SOLN","81000008","CDM","0636","RC","J2401","HCPCS","63323-477-27","NDC","facility","outpatient","0.050000","ML","PN","0.45","0.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NICARDIPINE 2.5 MG/ML INTERVENTIONAL INJ SOLN","81000008","CDM","0636","RC","J2404","HCPCS","0143-9689-10","NDC","facility","outpatient","0.037500","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NICARDIPINE HCL IN NACL 40-0.83 MG/200ML-% IV SOLN","81000008","CDM","0636","RC","J2404","HCPCS","43066-016-10","NDC","facility","outpatient","0.788770","ML","JZ","2.70","2.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NICARDIPINE HCL IN NACL 40-0.83 MG/200ML-% IV SOLN","81000008","CDM","0636","RC","J2404","HCPCS","10122-325-10","NDC","facility","outpatient","1.500000","ML","JZ","3.05","3.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NICARDIPINE HCL IN NACL 40-0.83 MG/200ML-% IV SOLN","81000008","CDM","0636","RC","J2404","HCPCS","0143-9633-01","NDC","facility","outpatient","0.500000","ML","JZ","2.44","2.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","0409-4755-03","NDC","facility","outpatient","0.700000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","0641-6078-25","NDC","facility","outpatient","0.669009","ML","JZ","16.26","16.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","60505-6130-5","NDC","facility","outpatient","0.597928","ML","JZ","17.95","17.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","70860-776-02","NDC","facility","outpatient","0.500000","ML","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","0641-6078-25","NDC","facility","outpatient","12.250000","ML",,"16.33","16.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","0641-6079-01","NDC","facility","outpatient","0.500000","ML",,"4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","16729-298-05","NDC","facility","outpatient","0.500000","ML",,"4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","23155-549-31","NDC","facility","outpatient","0.500000","ML",,"4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","72266-124-01","NDC","facility","outpatient","18.500000","ML",,"4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","0409-4759-01","NDC","facility","outpatient","0.500000","ML","PN","4.54","4.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","16729-298-05","NDC","facility","outpatient","0.500000","ML","PN","4.69","4.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","72266-124-01","NDC","facility","outpatient","0.530131","ML","PN","4.70","4.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","0641-6078-25","NDC","facility","outpatient","0.608108","ML","PN,JZ","9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","60505-6130-5","NDC","facility","outpatient","0.566945","ML","PN,JZ","9.29","9.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ONDANSETRON HCL 40 MG/20ML IJ SOLN","81000008","CDM","0636","RC","J2405","HCPCS","23155-549-31","NDC","facility","outpatient","0.530865","ML","PN","4.63","4.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PALIPERIDONE PALMITATE ER 234 MG/1.5ML IM SUSY","81000008","CDM","0636","RC","J2426","HCPCS","50458-564-01","NDC","facility","outpatient","0.006410","ML","JZ","44.87","44.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PALONOSETRON HCL 0.25 MG/5ML IV SOLN","81000008","CDM","0636","RC","J2469","HCPCS","16714-834-01","NDC","facility","outpatient","0.642857","ML","PN,JZ","186.72","186.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PALONOSETRON HCL 0.25 MG/5ML IV SOLN","81000008","CDM","0636","RC","J2469","HCPCS","60505-6193-1","NDC","facility","outpatient","0.500000","ML","PN,JZ","65.36","65.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","J2470","HCPCS","0008-0923-55","NDC","facility","outpatient","1.615384","UN",,"56.50","56.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","J2470","HCPCS","55150-202-10","NDC","facility","outpatient","1.216900","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","J2470","HCPCS","25021-751-10","NDC","facility","outpatient","1.355158","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PEGFILGRASTIM 6 MG/0.6ML SC SOSY","81000008","CDM","0636","RC","J2506","HCPCS","55513-190-01","NDC","facility","outpatient","0.083333","ML","PN,JZ","1123.15","1123.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEGFILGRASTIM 6 MG/0.6ML SC PSKT","81000008","CDM","0636","RC","J2506","HCPCS","55513-192-01","NDC","facility","outpatient","0.056666","ML","PN,JZ","1097.07","1097.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR","81000008","CDM","0636","RC","J2540","HCPCS","0049-0530-28","NDC","facility","outpatient","0.028571","UN","JZ","12.21","12.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR","81000008","CDM","0636","RC","J2540","HCPCS","0049-0520-83","NDC","facility","outpatient","0.141176","UN",,"12.21","12.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0206-8854-16","NDC","facility","outpatient","0.404040","UN","JZ","28.84","28.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0206-8855-16","NDC","facility","outpatient","0.250000","UN","JZ","28.84","28.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0409-3378-11","NDC","facility","outpatient","0.538461","UN","JZ","33.93","33.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0409-3379-04","NDC","facility","outpatient","0.250000","UN","JZ","32.76","32.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0409-3385-11","NDC","facility","outpatient","0.333333","UN","JZ","29.28","29.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0781-3113-95","NDC","facility","outpatient","0.410436","UN","JZ","43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0781-3114-95","NDC","facility","outpatient","0.266091","UN","JZ","40.92","40.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0781-9213-90","NDC","facility","outpatient","0.333333","UN","JZ","43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","44567-803-10","NDC","facility","outpatient","0.279850","UN","JZ","18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","55150-120-30","NDC","facility","outpatient","0.441253","UN","JZ","24.57","24.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 2.25 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","64679-034-01","NDC","facility","outpatient","0.500000","UN",,"50.75","50.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","55150-120-30","NDC","facility","outpatient","0.333333","UN",,"50.76","50.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR","81000008","CDM","0636","RC","J2543","HCPCS","55150-119-30","NDC","facility","outpatient","0.380000","UN",,"5.68","5.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0781-3113-95","NDC","facility","outpatient","0.736322","UN",,"40.79","40.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","55150-121-50","NDC","facility","outpatient","0.284246","UN","JZ","47.01","47.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","60505-6159-4","NDC","facility","outpatient","0.305555","UN","JZ","38.06","38.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","64679-012-01","NDC","facility","outpatient","0.258000","UN","JZ","48.21","48.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","65219-436-02","NDC","facility","outpatient","0.400673","UN","JZ","25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","72485-403-01","NDC","facility","outpatient","0.333333","UN","JZ","39.99","39.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 4.5 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","72485-404-01","NDC","facility","outpatient","0.250000","UN","JZ","37.98","37.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PIPERACILLIN/TAZOBACTAM 2.25 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","44567-801-10","NDC","facility","outpatient","0.500000","UN",,"6.01","6.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0206-8854-16","NDC","facility","outpatient","0.583333","UN",,"28.84","28.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 3.375 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0409-3378-11","NDC","facility","outpatient","16.666666","ML",,"33.93","33.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 2.25 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J2543","HCPCS","0781-3110-95","NDC","facility","outpatient","0.545275","UN",,"43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2560","HCPCS","0641-0477-25","NDC","facility","outpatient","0.600000","ML","JZ","194.48","194.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2560","HCPCS","14789-128-07","NDC","facility","outpatient","1.477124","ML","JZ","140.8","140.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2560","HCPCS","42494-416-25","NDC","facility","outpatient","0.807017","ML","JZ","135.9","135.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2560","HCPCS","0641-0476-25","NDC","facility","outpatient","1.000000","ML",,"126.48","126.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL 65MG/ML INJ (PEDIATRIC) SH","81000008","CDM","0636","RC","J2560","HCPCS","14789-127-07","NDC","facility","outpatient","2.095238","ML",,"112","112",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2560","HCPCS","42494-415-25","NDC","facility","outpatient","1.214285","ML",,"101.99","101.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J2590","HCPCS","63323-012-01","NDC","facility","outpatient","5.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J2590","HCPCS","63323-012-10","NDC","facility","outpatient","1.800000","ML",,"7.34","7.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN-LACTATED RINGERS 30 UNIT/500ML IV SOLN","81000008","CDM","0636","RC","J2590","HCPCS","70092-1071-24","NDC","facility","outpatient","204.918032","ML",,"70.62","70.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN-LACTATED RINGERS 30 UNIT/500ML IV SOLN","81000008","CDM","0636","RC","J2590","HCPCS","71285-6039-1","NDC","facility","outpatient","166.666666","ML",,"30.75","30.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 30 UNITS/500 ML LACTATED RINGERS IV DRIP FOR INDUCTION (PREMIX) SH","81000008","CDM","0636","RC","J2590","HCPCS","72196-6039-1","NDC","facility","outpatient","166.666666","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 30 UNITS/500 ML LACTATED RINGERS IV DRIP FOR INDUCTION (PREMIX) SH","81000008","CDM","0636","RC","J2590","HCPCS","99999-0006-31","NDC","facility","outpatient","166.666666","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXYTOCIN 10 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J2590","HCPCS","42023-116-25","NDC","facility","outpatient","1.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J2597","HCPCS","65219-295-10","NDC","facility","outpatient","0.247391","ML","PN","28.94","28.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J2597","HCPCS","25021-460-01","NDC","facility","outpatient","0.250000","ML",,"107.1","107.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J2597","HCPCS","69918-901-10","NDC","facility","outpatient","0.245096","ML",,"87.84","87.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DESMOPRESSIN ACETATE PF 4 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J2597","HCPCS","69918-899-01","NDC","facility","outpatient","0.250000","ML","JZ","114.64","114.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN 20 UNIT/ML IV SOLN","81000008","CDM","0636","RC","J2598","HCPCS","55150-370-01","NDC","facility","outpatient","0.050000","ML","JZ","29.25","29.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN 0.2 UNIT/ML IV SOLN","81000008","CDM","0636","RC","J2598","HCPCS","42023-237-10","NDC","facility","outpatient","5.122950","ML","JZ","63.72","63.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN 20 UNIT/ML IJ SOLN (IO)","81000008","CDM","0636","RC","J2598","HCPCS","42023-164-25","NDC","facility","outpatient","0.057488","ML","JZ","32.02","32.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VASOPRESSIN-SODIUM CHLORIDE 20-0.9 UT/100ML-% IV SOLN","81000008","CDM","0636","RC","J2598","HCPCS","0338-9640-12","NDC","facility","outpatient","25.000000","ML","JZ","29.25","29.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROCAINAMIDE HCL 500 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2690","HCPCS","14789-900-07","NDC","facility","outpatient","1.000000","ML","JZ","1800","1800",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROCAINAMIDE HCL 500 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2690","HCPCS","14789-900-07","NDC","facility","outpatient","1.333333","ML",,"2880","2880",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","0069-0234-01","NDC","facility","outpatient","1.000000","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","0264-4850-01","NDC","facility","outpatient","1.000000","ML","JZ","1.68","1.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","0409-4699-24","NDC","facility","outpatient","1.095238","ML","JZ","1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","25021-608-50","NDC","facility","outpatient","0.999835","ML","JZ","2.32","2.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","25021-608-51","NDC","facility","outpatient","1.181818","ML","JZ","2.28","2.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","63323-269-29","NDC","facility","outpatient","1.000000","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","63323-269-50","NDC","facility","outpatient","1.217054","ML","JZ","2.52","2.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","63323-269-65","NDC","facility","outpatient","1.145381","ML","JZ","2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 200 MG/20ML IV EMUL","81000008","CDM","0636","RC","J2704","HCPCS","0409-4699-30","NDC","facility","outpatient","1.130096","ML","JZ","4.29","4.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROPOFOL 200 MG/20ML IV EMUL","81000008","CDM","0636","RC","J2704","HCPCS","0409-4699-30","NDC","facility","outpatient","0.962500","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","16714-977-01","NDC","facility","outpatient","1.000000","ML",,"1.81","1.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","25021-608-50","NDC","facility","outpatient","1.154712","ML",,"2.71","2.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","63323-269-29","NDC","facility","outpatient","2.242038","ML",,"27.99","27.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROPOFOL 10MG/ML IV EMUL - CONSOLIDATED","81000008","CDM","0636","RC","J2704","HCPCS","63323-269-65","NDC","facility","outpatient","1.113402","ML",,"2.34","2.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN","81000008","CDM","0636","RC","J2710","HCPCS","76014-003-10","NDC","facility","outpatient","0.790909","ML",,"13.38","13.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROTAMINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2720","HCPCS","63323-229-30","NDC","facility","outpatient","1.000000","ML",,"14.48","14.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROTAMINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2720","HCPCS","63323-229-30","NDC","facility","outpatient","1.609504","ML","JZ","13.69","13.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PROTAMINE SULFATE 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J2720","HCPCS","63323-229-05","NDC","facility","outpatient","1.086304","ML","JZ","25.59","25.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHENTOLAMINE MESYLATE 5 MG IJ SOLR","81000008","CDM","0636","RC","J2760","HCPCS","0143-9564-01","NDC","facility","outpatient","5.000000","ME",,"2500","2500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHENTOLAMINE MESYLATE 5 MG IJ SOLR","81000008","CDM","0636","RC","J2760","HCPCS","68094-101-20","NDC","facility","outpatient","1.000000","UN",,"2015.04","2015.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2765","HCPCS","0409-3414-01","NDC","facility","outpatient","2.189063","ML","JZ","66.73","66.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2765","HCPCS","0703-4502-04","NDC","facility","outpatient","2.120879","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2765","HCPCS","23155-240-41","NDC","facility","outpatient","1.435897","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","81000008","CDM","0636","RC","J2765","HCPCS","0409-3414-01","NDC","facility","outpatient","2.000000","ML","PN,JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"REGADENOSON 0.4 MG/5ML IV SOLN","81000008","CDM","0636","RC","J2785","HCPCS","0469-6501-89","NDC","facility","outpatient","2.840909","ML",,"258.70","258.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"REGADENOSON 0.4 MG/5ML IV SOLN","81000008","CDM","0636","RC","J2785","HCPCS","43598-616-11","NDC","facility","outpatient","1.250000","ML",,"165.75","165.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"REGADENOSON 0.4 MG/5ML IV SOLN","81000008","CDM","0636","RC","J2785","HCPCS","55150-443-01","NDC","facility","outpatient","1.250000","ML",,"243.75","243.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"REGADENOSON 0.4 MG/5ML IV SOLN","81000008","CDM","0636","RC","J2785","HCPCS","71288-201-85","NDC","facility","outpatient","1.379390","ML",,"40.96","40.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY","81000008","CDM","0636","RC","J2790","HCPCS","0562-7805-01","NDC","facility","outpatient","1.296296","UN",,"819.91","819.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY","81000008","CDM","0636","RC","J2790","HCPCS","13533-631-02","NDC","facility","outpatient","1.000000","UN",,"646.1","646.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROMIPLOSTIM 125 MCG SC SOLR","81000008","CDM","0636","RC","J2796","HCPCS","55513-223-01","NDC","facility","outpatient","0.080000","UN","JZ","457.92","457.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ROMIPLOSTIM 125 MCG SC SOLR","81000008","CDM","0636","RC","J2796","HCPCS","55513-223-01","NDC","facility","outpatient","0.080000","UN","PN","474.28","474.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ROMIPLOSTIM 125 MCG SC SOLR","81000008","CDM","0636","RC","J2796","HCPCS","55513-223-01","NDC","facility","outpatient","0.021666","ML","PN,JW","128.45","128.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"ROMIPLOSTIM 125 MCG SC SOLR","81000008","CDM","0636","RC","J2796","HCPCS","55513-223-01","NDC","facility","outpatient","0.109090","UN","PN,JZ","472.49","472.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SINCALIDE 5 MCG IJ SOLR","81000008","CDM","0636","RC","J2805","HCPCS","0270-0556-15","NDC","facility","outpatient","0.279500","UN","JZ","365.32","365.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SINCALIDE 5 MCG IJ SOLR","81000008","CDM","0636","RC","J2805","HCPCS","72266-248-01","NDC","facility","outpatient","0.358000","UN","JZ","381.53","381.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN","81000008","CDM","0636","RC","J2916","HCPCS","0143-9570-10","NDC","facility","outpatient","1.148148","ML","JZ","48.75","48.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN","81000008","CDM","0636","RC","J2916","HCPCS","0024-2792-10","NDC","facility","outpatient","1.000000","ML","PN","49.61","49.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN","81000008","CDM","0636","RC","J2916","HCPCS","0024-2792-10","NDC","facility","outpatient","1.018348","ML","PN,JZ","49.13","49.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN","81000008","CDM","0636","RC","J2916","HCPCS","0143-9570-10","NDC","facility","outpatient","1.000000","ML","PN,JZ","49.61","49.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0009-0039-28","NDC","facility","outpatient","0.118489","UN","JZ","20.45","20.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0009-0047-22","NDC","facility","outpatient","0.052199","UN","JZ","4.46","4.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0009-0018-20","NDC","facility","outpatient","5.000000","ME",,"2.69","2.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0009-0047-22","NDC","facility","outpatient","0.039314","UN",,"10.71","10.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0009-0698-01","NDC","facility","outpatient","5.000000","ME",,"1.72","1.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0009-0018-20","NDC","facility","outpatient","0.005000","UN","JZ","2.69","2.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0143-9753-01","NDC","facility","outpatient","0.125000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","43598-127-45","NDC","facility","outpatient","0.137000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0009-0047-22","NDC","facility","outpatient","0.050685","UN","PN,JZ","3.64","3.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","43598-127-25","NDC","facility","outpatient","0.225000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 500 MG IJ SOLR","81000008","CDM","0636","RC","J2919","HCPCS","0009-0003-02","NDC","facility","outpatient","0.010000","UN","JZ","3.98","3.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","81000008","CDM","0636","RC","J2920","HCPCS","0009-0039-28","NDC","facility","outpatient","0.473333","UN","JZ","56.69","56.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR","81000008","CDM","0636","RC","J2920","HCPCS","0143-9753-01","NDC","facility","outpatient","0.125000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR","81000008","CDM","0636","RC","J2920","HCPCS","43598-127-45","NDC","facility","outpatient","0.125000","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0636","RC","J2930","HCPCS","0009-0018-20","NDC","facility","outpatient","0.118750","UN","JZ","59.66","59.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0636","RC","J2930","HCPCS","0009-0047-22","NDC","facility","outpatient","1.173327","UN","JZ","87.5","87.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR","81000008","CDM","0636","RC","J2930","HCPCS","0009-0018-20","NDC","facility","outpatient","0.123684","UN",,"62.79","62.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0636","RC","J2930","HCPCS","0009-0047-22","NDC","facility","outpatient","0.550588","UN",,"61.34","61.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","81000008","CDM","0636","RC","J2930","HCPCS","0009-0047-22","NDC","facility","outpatient","0.881538","UN","PN,JZ","84.95","84.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLPREDNISOLONE NA SUC (PF) 1000 MG IJ SOLR","81000008","CDM","0636","RC","J2930","HCPCS","63323-265-30","NDC","facility","outpatient","0.119791","UN","JZ","32.53","32.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALTEPLASE 2 MG IJ SOLR","81000008","CDM","0636","RC","J2997","HCPCS","50242-041-64","NDC","facility","outpatient","0.608843","UN","JZ","468.45","468.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALTEPLASE 2 MG IJ SOLR","81000008","CDM","0636","RC","J2997","HCPCS","50242-041-64","NDC","facility","outpatient","0.500000","UN","PN,JZ","478.84","478.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN","81000008","CDM","0636","RC","J3010","HCPCS","0409-9094-25","NDC","facility","outpatient","2.007139","ML",,"68.52","68.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE 50MCG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3010","HCPCS","0641-6027-25","NDC","facility","outpatient","1.097826","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE 50MCG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3010","HCPCS","63323-806-02","NDC","facility","outpatient","1.316666","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 2500MCG/250ML NS IV DRIP (PREMIX) SH","81000008","CDM","0636","RC","J3010","HCPCS","70092-1093-37","NDC","facility","outpatient","11.159420","ML",,"7.90","7.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 2MCG/ML, BUPIVACAINE PF 0.1% IN NS 250ML PCEA (PREMIX)","81000008","CDM","0636","RC","J3010","HCPCS","70092-1160-37","NDC","facility","outpatient","62.302158","ML",,"90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL 1500MCG/30ML NS IV DRIP (PREMIX) SH","81000008","CDM","0636","RC","J3010","HCPCS","70092-1180-79","NDC","facility","outpatient","2.000000","ML",,"13.37","13.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","81000008","CDM","0636","RC","J3010","HCPCS","0409-9094-22","NDC","facility","outpatient","2.000000","ML","PN","90","90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","81000008","CDM","0636","RC","J3010","HCPCS","0409-9094-22","NDC","facility","outpatient","1.909167","ML",,"78.96","78.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EPTINEZUMAB-JJMR 100 MG/ML IV SOLN","81000008","CDM","0636","RC","J3032","HCPCS","67386-130-51","NDC","facility","outpatient","0.010000","ML","PN,JZ","43.27","43.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TENECTEPLASE 50MG/10ML INJ (FOR STROKE) SH","81000008","CDM","0636","RC","J3101","HCPCS","50242-120-47","NDC","facility","outpatient","0.032108","UN","JZ","484.28","484.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TERBUTALINE SULFATE 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3105","HCPCS","0143-9746-10","NDC","facility","outpatient","0.250000","ML","JZ","73.15","73.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TERBUTALINE SULFATE 1 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3105","HCPCS","63323-665-01","NDC","facility","outpatient","0.250000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"THYROTROPIN ALFA 0.9 MG IM SOLR","81000008","CDM","0636","RC","J3240","HCPCS","58468-0030-2","NDC","facility","outpatient","1.259259","UN",,"5631.82","5631.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TEPROTUMUMAB-TRBW 500 MG IV SOLR","81000008","CDM","0636","RC","J3241","HCPCS","75987-130-15","NDC","facility","outpatient","0.019926","UN","PN","573.85","573.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TEPROTUMUMAB-TRBW 500 MG IV SOLR","81000008","CDM","0636","RC","J3241","HCPCS","75987-130-15","NDC","facility","outpatient","12.552238","ME","PN,JW","385.77","385.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"TEPROTUMUMAB-TRBW 500 MG IV SOLR","81000008","CDM","0636","RC","J3241","HCPCS","75987-130-15","NDC","facility","outpatient","0.022293","UN","PN,JZ","521.38","521.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TOBRAMYCIN SULFATE 40 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3260","HCPCS","0409-3578-01","NDC","facility","outpatient","1.500000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN","81000008","CDM","0636","RC","J3260","HCPCS","67457-428-30","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN SULFATE 40 MG/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3260","HCPCS","67457-473-22","NDC","facility","outpatient","2.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 40 MG/ML IO SUSP","81000008","CDM","0636","RC","J3300","HCPCS","0065-0543-01","NDC","facility","outpatient","0.025000","ML",,"113.28","113.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP","81000008","CDM","0636","RC","J3301","HCPCS","0003-0293-05","NDC","facility","outpatient","0.327170","ML","JZ","22.83","22.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP","81000008","CDM","0636","RC","J3301","HCPCS","70121-1049-5","NDC","facility","outpatient","0.250000","ML","JZ","18.15","18.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP","81000008","CDM","0636","RC","J3301","HCPCS","0003-0494-20","NDC","facility","outpatient","0.433333","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP","81000008","CDM","0636","RC","J3301","HCPCS","67457-621-02","NDC","facility","outpatient","0.750000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIAZEPAM 5 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3360","HCPCS","0409-1273-32","NDC","facility","outpatient","1.105000","ML",,"91.53","91.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","16714-309-01","NDC","facility","outpatient","0.500000","UN","JZ","67.37","67.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 1250MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","0143-9152-01","NDC","facility","outpatient","0.333333","UN",,"56.28","56.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL IN DEXTROSE 750-5 MG/150ML-% IV SOLN","81000008","CDM","0636","RC","J3370","HCPCS","0338-3580-48","NDC","facility","outpatient","90.046564","ML",,"47.77","47.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1500MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","0409-3515-01","NDC","facility","outpatient","0.521531","UN",,"80.10","80.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 500 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J3370","HCPCS","0409-4332-01","NDC","facility","outpatient","1.121212","UN",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","0409-6533-01","NDC","facility","outpatient","125.000000","ML",,"67.37","67.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","0409-6533-21","NDC","facility","outpatient","0.567796","UN",,"68.39","68.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1250MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","55150-471-01","NDC","facility","outpatient","0.333333","UN",,"56.28","56.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 1 G IV SOLR","81000008","CDM","0636","RC","J3370","HCPCS","67457-340-01","NDC","facility","outpatient","0.500000","UN",,"62.56","62.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","0409-6533-21","NDC","facility","outpatient","0.653846","UN","JZ","63.83","63.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 750MG/250ML NS (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","0409-6531-02","NDC","facility","outpatient","0.533898","UN","JZ","41.34","41.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 1,000MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3370","HCPCS","0409-6533-01","NDC","facility","outpatient","658.389261","ME","JZ","67.76","67.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 5 MG/ML IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0636","RC","J3370","HCPCS","0338-3552-48","NDC","facility","outpatient","131.620553","ML","JZ","103.04","103.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 500 MG/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J3370","HCPCS","0409-4332-01","NDC","facility","outpatient","0.750000","UN","JZ","11.36","11.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN HCL IN NACL 1.25-0.9 GM/250ML-% IV SOLN","81000008","CDM","0636","RC","J3370","HCPCS","70092-9054-05","NDC","facility","outpatient","83.333333","ML",,"61.83","61.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 33MG/ML FORTIFIED OPHTH SOLN *COMPOUNDED* SH","81000008","CDM","0636","RC","J3370","HCPCS","99999-0015-92","NDC","facility","outpatient","135.000000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1MG/0.1ML NS INTRAVITREAL SOLN *COMPOUNDED* SH","81000008","CDM","0636","RC","J3370","HCPCS","99999-0038-26","NDC","facility","outpatient","0.500000","ML",,"30","30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN HCL 1 G IV SOLR","81000008","CDM","0636","RC","J3371","HCPCS","67457-340-01","NDC","facility","outpatient","0.605263","UN","JZ","67.38","67.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN 1250MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3371","HCPCS","67457-823-99","NDC","facility","outpatient","0.333333","UN","JZ","56.28","56.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VANCOMYCIN HCL 1 G IV SOLR","81000008","CDM","0636","RC","J3371","HCPCS","67457-340-01","NDC","facility","outpatient","0.500000","UN",,"67.38","67.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VANCOMYCIN 1250MG/250ML 0.9% NACL (VIAL-MATE)","81000008","CDM","0636","RC","J3371","HCPCS","67457-823-99","NDC","facility","outpatient","0.404040","UN",,"56.28","56.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VEDOLIZUMAB 300 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J3380","HCPCS","64764-300-20","NDC","facility","outpatient","0.003333","UN","JZ","52.00","52.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYDROXYZINE HCL 50 MG/ML IM SOLN","81000008","CDM","0636","RC","J3410","HCPCS","0517-5601-25","NDC","facility","outpatient","0.583333","ML",,"120.50","120.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3411","HCPCS","72603-139-01","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3411","HCPCS","67457-196-02","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3411","HCPCS","63323-013-02","NDC","facility","outpatient","1.309063","ML",,"45.11","45.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3411","HCPCS","43598-050-25","NDC","facility","outpatient","1.494845","ML",,"30.50","30.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3411","HCPCS","0641-6228-25","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3411","HCPCS","25021-500-02","NDC","facility","outpatient","1.000000","ML",,"41.79","41.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"THIAMINE HCL 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3411","HCPCS","43598-050-11","NDC","facility","outpatient","1.000000","ML",,"37.92","37.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J3420","HCPCS","0143-9621-25","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J3420","HCPCS","63323-044-00","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J3420","HCPCS","70069-005-10","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J3420","HCPCS","71288-303-01","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","81000008","CDM","0636","RC","J3420","HCPCS","0517-0031-25","NDC","facility","outpatient","1.137931","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HYDROXOCOBALAMIN 5 G IV SOLR","81000008","CDM","0636","RC","J3424","HCPCS","50633-310-11","NDC","facility","outpatient","0.045000","UN",,"23.26","23.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PHYTONADIONE 1 MG/0.5ML IJ SOLN","81000008","CDM","0636","RC","J3430","HCPCS","76329-1240-1","NDC","facility","outpatient","0.488690","ML","JZ","207.73","207.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PHYTONADIONE 10 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3430","HCPCS","0409-9158-01","NDC","facility","outpatient","0.106941","ML",,"38.27","38.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J3465","HCPCS","70436-029-80","NDC","facility","outpatient","0.001000","UN","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J3465","HCPCS","0049-3190-28","NDC","facility","outpatient","0.000825","UN","JZ","58.76","58.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYALURONIDASE OVINE 200 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J3471","HCPCS","24208-002-02","NDC","facility","outpatient","0.005000","ML","JZ","3.71","3.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","J3473","HCPCS","18657-117-04","NDC","facility","outpatient","0.006648","ML","JZ","3.30","3.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0409-6727-23","NDC","facility","outpatient","50.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0409-6729-11","NDC","facility","outpatient","12.500000","ML",,"34.04","34.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0409-6729-24","NDC","facility","outpatient","16.847826","ML",,"31.52","31.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 2-5 GM/50ML-% IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0517-2602-25","NDC","facility","outpatient","62.500000","ML",,"62.92","62.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","25021-612-81","NDC","facility","outpatient","15.500000","ML",,"35.18","35.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","44567-420-24","NDC","facility","outpatient","12.500000","ML",,"18.75","18.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","47335-992-01","NDC","facility","outpatient","16.346153","ML",,"27.56","27.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 50 % IJ SOLN","81000008","CDM","0636","RC","J3475","HCPCS","63323-064-03","NDC","facility","outpatient","1.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 4G/100ML SW IV DRIP (PREMIX) SH","81000008","CDM","0636","RC","J3475","HCPCS","63323-106-01","NDC","facility","outpatient","19.121004","ML",,"9.38","9.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","63323-106-05","NDC","facility","outpatient","16.065365","ML",,"26.50","26.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0338-1709-40","NDC","facility","outpatient","60.429447","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","63323-108-01","NDC","facility","outpatient","78.571428","ML",,"36.59","36.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0409-6729-11","NDC","facility","outpatient","14.112903","ML","PN","34.04","34.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0409-6729-24","NDC","facility","outpatient","12.500000","ML","PN","31.72","31.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MAGNESIUM SULFATE 50 % IJ SOLN","81000008","CDM","0636","RC","J3475","HCPCS","63323-064-03","NDC","facility","outpatient","1.022727","ML","PN","36.48","36.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","67457-567-00","NDC","facility","outpatient","50.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0338-1708-40","NDC","facility","outpatient","12.500000","ML",,"26.42","26.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN","81000008","CDM","0636","RC","J3475","HCPCS","0264-4400-54","NDC","facility","outpatient","50.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0409-6653-05","NDC","facility","outpatient","1.358974","ML","JZ","3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","63323-965-01","NDC","facility","outpatient","1.000000","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NACL 0.45% WITH KCL 20 MEQ 1000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0338-0704-34","NDC","facility","outpatient","300.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0338-0705-48","NDC","facility","outpatient","10.682302","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0338-0709-48","NDC","facility","outpatient","25.135802","ML",,"14.79","14.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.9% WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0338-0803-04","NDC","facility","outpatient","156.637168","ML",,"6.80","6.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0338-0811-04","NDC","facility","outpatient","100.000000","ML",,"9.1","9.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0409-7075-26","NDC","facility","outpatient","10.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0990-7074-26","NDC","facility","outpatient","23.265306","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0990-7075-26","NDC","facility","outpatient","10.000000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0990-7111-09","NDC","facility","outpatient","100.000000","ML",,"1.50","1.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","14789-136-07","NDC","facility","outpatient","1.000000","ML",,"13.44","13.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% WITH KCL 20 MEQ 1000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0338-0691-04","NDC","facility","outpatient","233.333333","ML",,"9.1","9.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% WITH KCL 20 MEQ 1000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0338-0691-04","NDC","facility","outpatient","136.363636","ML","PN","8.46","8.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0990-7074-26","NDC","facility","outpatient","20.000000","ML","PN","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","63323-965-10","NDC","facility","outpatient","1.000000","ML","PN","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","63323-965-10","NDC","facility","outpatient","1.000000","ML","PN,JW","0.24","0.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","63323-965-03","NDC","facility","outpatient","1.210526","ML","PN,JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","63323-965-10","NDC","facility","outpatient","1.000000","ML","PN,JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0338-0709-48","NDC","facility","outpatient","20.000000","ML","PN","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"D5W - NACL 0.45% WITH KCL 40 MEQ 1,000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0338-0675-04","NDC","facility","outpatient","50.000000","ML",,"4.2","4.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0338-0671-04","NDC","facility","outpatient","171.910112","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.9% WITH KCL 20 MEQ 1,000 ML","81000008","CDM","0636","RC","J3480","HCPCS","0264-7652-00","NDC","facility","outpatient","100.000000","ML",,"4.30","4.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","63323-965-02","NDC","facility","outpatient","1.000000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","63323-965-03","NDC","facility","outpatient","1.000000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","63323-965-10","NDC","facility","outpatient","1.800000","ML","JZ","7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN","81000008","CDM","0636","RC","J3480","HCPCS","0409-7074-26","NDC","facility","outpatient","20.000000","ML","JZ","15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ZIPRASIDONE MESYLATE 20 MG IM SOLR","81000008","CDM","0636","RC","J3486","HCPCS","0049-3920-83","NDC","facility","outpatient","2.277777","UN","JZ","251.27","251.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ZIPRASIDONE MESYLATE 20 MG IM SOLR","81000008","CDM","0636","RC","J3486","HCPCS","43598-848-58","NDC","facility","outpatient","0.605263","UN",,"156.88","156.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZIPRASIDONE MESYLATE 20 MG IM SOLR","81000008","CDM","0636","RC","J3486","HCPCS","72266-160-10","NDC","facility","outpatient","1.250000","UN",,"127.88","127.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ZOLEDRONIC ACID 5 MG/100ML IV SOLN","81000008","CDM","0636","RC","J3489","HCPCS","25021-830-82","NDC","facility","outpatient","20.000000","ML","PN","420","420",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ZOLEDRONIC ACID 4 MG/100ML IV SOLN","81000008","CDM","0636","RC","J3489","HCPCS","25021-826-82","NDC","facility","outpatient","27.326771","ML","PN","242.59","242.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ZOLEDRONIC ACID 4 MG/100ML IV SOLN","81000008","CDM","0636","RC","J3489","HCPCS","25021-826-82","NDC","facility","outpatient","20.625000","ML",,"243.75","243.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0143-9637-10","NDC","facility","outpatient","2.600000","ML","JZ","30.83","30.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0143-9785-10","NDC","facility","outpatient","3.115447","ML","JZ","90.78","90.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METRONIDAZOLE 500 MG/100ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0409-0152-24","NDC","facility","outpatient","100.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0409-1159-01","NDC","facility","outpatient","16.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0409-1159-02","NDC","facility","outpatient","230.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0409-3613-01","NDC","facility","outpatient","0.750000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0517-4601-25","NDC","facility","outpatient","1.000000","ML","JZ","113.75","113.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DILTIAZEM HCL 25 MG/5ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0641-6013-10","NDC","facility","outpatient","2.588235","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DILTIAZEM HCL 50 MG/10ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0641-6014-10","NDC","facility","outpatient","2.222222","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0636","RC","J3490","HCPCS","0641-6117-10","NDC","facility","outpatient","0.316066","UN","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","0781-3289-09","NDC","facility","outpatient","25.000000","ML","JZ","51.98","51.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000008","CDM","0636","RC","J3490","HCPCS","39822-1000-1","NDC","facility","outpatient","9.981072","ML","JZ","42.27","42.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","81000008","CDM","0636","RC","J3490","HCPCS","43547-543-01","NDC","facility","outpatient","0.862500","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","81000008","CDM","0636","RC","J3490","HCPCS","55150-117-20","NDC","facility","outpatient","0.500000","UN","JZ","51.1","51.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0636","RC","J3490","HCPCS","55150-172-30","NDC","facility","outpatient","20.835000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BUPIVACAINE HCL (PF) 0.75 % IJ SOLN","81000008","CDM","0636","RC","J3490","HCPCS","63323-472-37","NDC","facility","outpatient","20.835000","ML","JZ","43.9","43.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3490","HCPCS","63323-739-12","NDC","facility","outpatient","4.807096","ML","JZ","56.25","56.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NOREPINEPHRINE 8MG/250ML D5W SH (NON-WT BASED DOSING)","81000008","CDM","0636","RC","J3490","HCPCS","70092-9036-17","NDC","facility","outpatient","248.418276","ML","JZ","76.66","76.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","70860-784-05","NDC","facility","outpatient","3.000000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3490","HCPCS","0641-6022-25","NDC","facility","outpatient","2.695114","ML","JZ","74.47","74.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VALPROATE SODIUM 100 MG/ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","70860-784-41","NDC","facility","outpatient","1.000000","ML","JZ","8.4","8.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000008","CDM","0636","RC","J3490","HCPCS","81284-611-00","NDC","facility","outpatient","10.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000008","CDM","0636","RC","J3490","HCPCS","81284-611-10","NDC","facility","outpatient","10.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LABETALOL HCL 5MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3490","HCPCS","0409-2339-34","NDC","facility","outpatient","1.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3490","HCPCS","0409-3189-05","NDC","facility","outpatient","8.448349","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3490","HCPCS","0409-9558-05","NDC","facility","outpatient","6.230106","ML",,"69.33","69.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3490","HCPCS","0409-9558-10","NDC","facility","outpatient","9.633589","ML",,"71.57","71.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PIPERACILLIN/TAZOBACTAM 2.25 GM/100ML NS (MINIBAG)","81000008","CDM","0636","RC","J3490","HCPCS","0781-3110-95","NDC","facility","outpatient","0.500000","UN",,"43.08","43.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID 1000MG/10ML TOPICAL SOLN SH","81000008","CDM","0636","RC","J3490","HCPCS","39822-1000-1","NDC","facility","outpatient","10.000000","ML",,"52.5","52.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"VASOPRESSIN 0.2 UNIT/ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","42023-237-10","NDC","facility","outpatient","1.000000","ML",,"12.74","12.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ROCURONIUM BROMIDE 10 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3490","HCPCS","55150-225-05","NDC","facility","outpatient","7.857142","ML",,"219","219",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","67457-852-04","NDC","facility","outpatient","4.333333","ML",,"141.86","141.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NOREPINEPHRINE 8MG/250ML NS SH (NON-WT BASED DOSING)","81000008","CDM","0636","RC","J3490","HCPCS","70092-1035-05","NDC","facility","outpatient","307.692307","ML",,"289.25","289.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NOREPINEPHRINE 8MG/250ML NS SH (NON-WT BASED DOSING)","81000008","CDM","0636","RC","J3490","HCPCS","70092-1651-05","NDC","facility","outpatient","299.327354","ML",,"255.13","255.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NOREPINEPHRINE 8MG/250ML NS SH (NON-WT BASED DOSING)","81000008","CDM","0636","RC","J3490","HCPCS","71266-5015-2","NDC","facility","outpatient","274.444444","ML",,"328.91","328.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","80830-2329-1","NDC","facility","outpatient","100.000000","ML",,"172.2","172.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J3490","HCPCS","67457-433-22","NDC","facility","outpatient","1.554054","ML","PN,JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN","81000008","CDM","0636","RC","J3490","HCPCS","51754-0108-1","NDC","facility","outpatient","125.000000","ML",,"176.4","176.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT","81000008","CDM","0636","RC","J7168","HCPCS","63833-387-02","NDC","facility","outpatient","0.291032","UN","JZ","8.31","8.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR","81000008","CDM","0636","RC","J7198","HCPCS","64193-425-02","NDC","facility","outpatient","0.000400","UN","JZ","0.0038","0.0038",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEVONORGESTREL 19.5 MG IU IUD","81000008","CDM","0636","RC","J7296","HCPCS","50419-424-01","NDC","facility","outpatient","3.000000","EA",,"5552.6","5552.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVONORGESTREL 20.1 MCG/DAY IU IUD","81000008","CDM","0636","RC","J7297","HCPCS","0023-5858-01","NDC","facility","outpatient","1.000000","EA",,"4198.47","4198.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVONORGESTREL 20 MCG/DAY IU IUD","81000008","CDM","0636","RC","J7298","HCPCS","50419-423-01","NDC","facility","outpatient","1.571428","EA",,"5446.82","5446.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BIMATOPROST 10 MCG IO IMPL","81000008","CDM","0636","RC","J7351","HCPCS","0023-9652-01","NDC","facility","outpatient","0.100000","UN","JZ","712.36","712.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BIMATOPROST 10 MCG IO IMPL","81000008","CDM","0636","RC","J7351","HCPCS","0023-9652-01","NDC","facility","outpatient","1","EA",,"715.32","715.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 0.100000 IMPLANT"
"TACROLIMUS 1 MG PO CAPS","81000008","CDM","0636","RC","J7507","HCPCS","0469-0617-11","NDC","facility","outpatient","1.000000","UN",,"28.96","28.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 0.5 MG PO CAPS","81000008","CDM","0636","RC","J7507","HCPCS","0904-6623-61","NDC","facility","outpatient","1.277777","UN",,"15.41","15.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 5 MG PO CAPS","81000008","CDM","0636","RC","J7507","HCPCS","0904-6624-61","NDC","facility","outpatient","0.200000","UN",,"11","11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 0.5 MG PO CAPS","81000008","CDM","0636","RC","J7507","HCPCS","51079-817-20","NDC","facility","outpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 1 MG PO CAPS","81000008","CDM","0636","RC","J7507","HCPCS","51079-818-20","NDC","facility","outpatient","1.216216","UN",,"20.81","20.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TACROLIMUS 1 MG PO CAPS","81000008","CDM","0636","RC","J7507","HCPCS","0904-7097-61","NDC","facility","outpatient","2.071428","UN",,"9.02","9.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN","81000008","CDM","0636","RC","J7510","HCPCS","60432-212-08","NDC","facility","outpatient","1.833228","ML",,"3.00","3.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 20 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","60687-145-01","NDC","facility","outpatient","0.070481","UN",,"0.38","0.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 50 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","59651-489-01","NDC","facility","outpatient","0.020000","UN","PN","0.15","0.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","60687-134-01","NDC","facility","outpatient","0.100000","UN",,"1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 5 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","60687-122-01","NDC","facility","outpatient","0.636363","UN",,"3","3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 20 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","59746-175-06","NDC","facility","outpatient","0.056060","UN",,"0.40","0.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","59746-173-06","NDC","facility","outpatient","0.100000","UN",,"1.5","1.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","0054-0017-20","NDC","facility","outpatient","0.100000","UN",,"0.9","0.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 20 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","0054-0018-20","NDC","facility","outpatient","0.050000","UN",,"0.27","0.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 5 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","0054-8724-25","NDC","facility","outpatient","0.176470","UN",,"3","3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 1 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","0054-8739-25","NDC","facility","outpatient","1.000000","UN",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","0054-9817-25","NDC","facility","outpatient","0.100000","UN",,"0.69","0.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","0378-0641-01","NDC","facility","outpatient","0.100000","UN",,"2.25","2.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 10 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","0904-6923-61","NDC","facility","outpatient","0.100000","UN",,"0.86","0.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 20 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","0904-7127-61","NDC","facility","outpatient","0.056650","UN",,"0.26","0.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PREDNISONE 1 MG PO TABS","81000008","CDM","0636","RC","J7512","HCPCS","59651-484-01","NDC","facility","outpatient","1.000000","UN",,"4.24","4.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOSPORINE MODIFIED 25 MG PO CAPS","81000008","CDM","0636","RC","J7515","HCPCS","0093-9018-19","NDC","facility","outpatient","1.000000","UN",,"7.56","7.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 500 MG PO TABS","81000008","CDM","0636","RC","J7517","HCPCS","0004-0260-01","NDC","facility","outpatient","0.500000","UN",,"35.98","35.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 250 MG PO CAPS","81000008","CDM","0636","RC","J7517","HCPCS","51079-721-20","NDC","facility","outpatient","1.000000","UN",,"21.80","21.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE MOFETIL 500 MG PO TABS","81000008","CDM","0636","RC","J7517","HCPCS","60687-438-11","NDC","facility","outpatient","0.720858","UN",,"6.22","6.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE SODIUM 180 MG PO TBEC","81000008","CDM","0636","RC","J7518","HCPCS","68084-907-21","NDC","facility","outpatient","1.000000","UN",,"25.45","25.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE SODIUM 360 MG PO TBEC","81000008","CDM","0636","RC","J7518","HCPCS","0904-6786-61","NDC","facility","outpatient","0.642857","UN",,"25.87","25.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MYCOPHENOLATE SODIUM 360 MG PO TBEC","81000008","CDM","0636","RC","J7518","HCPCS","68084-918-25","NDC","facility","outpatient","0.500000","UN",,"23.75","23.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EVEROLIMUS 0.5 MG PO TABS","81000008","CDM","0636","RC","J7527","HCPCS","51991-380-99","NDC","facility","outpatient","0.500000","UN",,"65.07","65.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0636","RC","J7608","HCPCS","0517-7504-01","NDC","facility","outpatient","3.048442","ML",,"49.69","49.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0636","RC","J7608","HCPCS","0517-7504-25","NDC","facility","outpatient","3.000000","ML",,"51.48","51.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % ORAL SOLN CUSTOM CREATE","81000008","CDM","0636","RC","J7608","HCPCS","0517-7604-01","NDC","facility","outpatient","3.930131","ML",,"60.32","60.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % IN SOLN","81000008","CDM","0636","RC","J7608","HCPCS","0517-7604-25","NDC","facility","outpatient","4.000000","ML",,"60.34","60.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 10 % IN SOLN","81000008","CDM","0636","RC","J7608","HCPCS","63323-691-30","NDC","facility","outpatient","10.000000","ML",,"40.15","40.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ACETYLCYSTEINE 20 % IN SOLN","81000008","CDM","0636","RC","J7608","HCPCS","63323-694-04","NDC","facility","outpatient","4.000000","ML",,"67.25","67.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU","81000008","CDM","0636","RC","J7611","HCPCS","0487-9901-30","NDC","facility","outpatient","0.593939","UN",,"1.98","1.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL CONTINUOUS NEB SIMPLE SH","81000008","CDM","0636","RC","J7611","HCPCS","69374-330-05","NDC","facility","outpatient","0.221592","ML",,"2.2","2.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","81000008","CDM","0636","RC","J7613","HCPCS","0378-8270-93","NDC","facility","outpatient","1.117647","ML",,"3.91","3.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","81000008","CDM","0636","RC","J7613","HCPCS","0487-9501-01","NDC","facility","outpatient","1.531669","ML",,"4.76","4.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","81000008","CDM","0636","RC","J7613","HCPCS","76204-200-01","NDC","facility","outpatient","2.065326","ML",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DORNASE ALFA 2.5 MG/2.5ML IN SOLN","81000008","CDM","0636","RC","J7639","HCPCS","50242-100-40","NDC","facility","outpatient","0.916666","ML",,"166.45","166.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM BROMIDE 0.02 % IN SOLN","81000008","CDM","0636","RC","J7644","HCPCS","0487-9801-01","NDC","facility","outpatient","5.035971","ML",,"8.57","8.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM BROMIDE 0.02 % IN SOLN","81000008","CDM","0636","RC","J7644","HCPCS","60687-394-83","NDC","facility","outpatient","4.375000","ML",,"10.5","10.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM BROMIDE 0.02 % IN SOLN","81000008","CDM","0636","RC","J7644","HCPCS","76204-100-01","NDC","facility","outpatient","5.000000","ML",,"20.32","20.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.2% IV SOLN","81000008","CDM","0636","RC","J7799","HCPCS","63323-873-10","NDC","facility","outpatient","500.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MITOMYCIN 5MG IV SOLR CHEMO (PF) FOR OPHTH USE","81000008","CDM","0636","RC","J7999","HCPCS","72819-152-05","NDC","facility","outpatient","0.040000","UN",,"104.38","104.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MITOMYCIN 5MG IV SOLR CHEMO (PF) FOR OPHTH USE","81000008","CDM","0636","RC","J7999","HCPCS","16729-115-05","NDC","facility","outpatient","0.040000","UN",,"137.32","137.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MITOMYCIN 5MG IV SOLR CHEMO (PF) FOR OPHTH USE","81000008","CDM","0636","RC","J7999","HCPCS","65219-564-20","NDC","facility","outpatient","0.040000","UN",,"150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MITOMYCIN 5MG IV SOLR CHEMO (PF) FOR OPHTH USE","81000008","CDM","0636","RC","J7999","HCPCS","67457-518-05","NDC","facility","outpatient","0.040000","UN",,"187.5","187.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MITOMYCIN 5MG IV SOLR CHEMO (PF) FOR OPHTH USE","81000008","CDM","0636","RC","J7999","HCPCS","71288-137-20","NDC","facility","outpatient","0.040000","UN",,"300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 0.5 MG/5ML PO SOLN","81000008","CDM","0636","RC","J8540","HCPCS","0054-3177-63","NDC","facility","outpatient","0.761875","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 1 MG PO TABS","81000008","CDM","0636","RC","J8540","HCPCS","0054-8174-25","NDC","facility","outpatient","0.250000","UN",,"3.75","3.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 4 MG PO TABS","81000008","CDM","0636","RC","J8540","HCPCS","0054-8175-25","NDC","facility","outpatient","0.088188","UN",,"0.40","0.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 2 MG PO TABS","81000008","CDM","0636","RC","J8540","HCPCS","0054-8176-25","NDC","facility","outpatient","0.125000","UN",,"1.88","1.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 4 MG PO TABS","81000008","CDM","0636","RC","J8540","HCPCS","0904-7266-61","NDC","facility","outpatient","0.097711","UN",,"0.45","0.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXAMETHASONE 4 MG PO TABS","81000008","CDM","0636","RC","J8540","HCPCS","0054-8175-25","NDC","facility","outpatient","0.062500","UN","PN","0.34","0.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0069-3031-20","NDC","facility","outpatient","17.500000","ML","JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0143-9086-01","NDC","facility","outpatient","4.900000","ML","JZ","3.76","3.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN INTRAHEPATIC CHEMOEMBOLIZATION IN LC BEADS","81000008","CDM","0636","RC","J9000","HCPCS","0143-9277-01","NDC","facility","outpatient","0.200000","UN",,"410.33","410.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0069-3031-20","NDC","facility","outpatient","4.200000","ML","PN","71.62","71.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0069-3032-20","NDC","facility","outpatient","4.888888","ML","PN","38.89","38.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","45963-733-68","NDC","facility","outpatient","4.555555","ML","PN","49.75","49.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0069-3031-20","NDC","facility","outpatient","5.800000","ML","PN,JW","14.13","14.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0069-3032-20","NDC","facility","outpatient","6.000000","ML","PN,JW","7.07","7.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","45963-733-68","NDC","facility","outpatient","9.000000","ML","PN,JW","15.12","15.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0069-3031-20","NDC","facility","outpatient","4.773381","ML","PN,JZ","72.24","72.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0069-3032-20","NDC","facility","outpatient","4.946037","ML","PN,JZ","39.44","39.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","0143-9086-01","NDC","facility","outpatient","4.900000","ML","PN,JZ","60","60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","25021-207-25","NDC","facility","outpatient","4.970588","ML","PN,JZ","39.21","39.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL 2 MG/ML IV SOLN","81000008","CDM","0636","RC","J9000","HCPCS","45963-733-68","NDC","facility","outpatient","4.981818","ML","PN,JZ","57.29","57.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATEZOLIZUMAB 1200 MG/20ML IV SOLN","81000008","CDM","0636","RC","J9022","HCPCS","50242-917-01","NDC","facility","outpatient","0.166666","ML","JZ","163.86","163.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ATEZOLIZUMAB 1200 MG/20ML IV SOLN","81000008","CDM","0636","RC","J9022","HCPCS","50242-917-01","NDC","facility","outpatient","0.246867","ML","PN,JZ","128.09","128.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZACITIDINE 100 MG IJ SUSR","81000008","CDM","0636","RC","J9025","HCPCS","71288-115-30","NDC","facility","outpatient","0.010000","UN","PN,JZ","0.27","0.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"AZACITIDINE 100 MG IJ SUSR","81000008","CDM","0636","RC","J9025","HCPCS","71288-115-30","NDC","facility","outpatient","0.010000","UN","PN","0.27","0.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"AZACITIDINE 100 MG/10ML IJ SUSR (WET SOLR VIAL)","81000008","CDM","0636","RC","J9025","HCPCS","72485-201-01","NDC","facility","outpatient","0.026666","UN","PN","0.29","0.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"AZACITIDINE 100 MG IJ SUSR","81000008","CDM","0636","RC","J9025","HCPCS","71288-115-30","NDC","facility","outpatient","1.000000","ME","PN,JW","0.19","0.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"AZACITIDINE 100 MG/10ML IJ SUSR (WET SOLR VIAL)","81000008","CDM","0636","RC","J9025","HCPCS","72485-201-01","NDC","facility","outpatient","2.500000","ME","PN,JW","0.19","0.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"BENDAMUSTINE HCL 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9034","HCPCS","63459-348-04","NDC","facility","outpatient","0.039919","ML","PN","89.51","89.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BEVACIZUMAB 25 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9035","HCPCS","50242-060-10","NDC","facility","outpatient","0.400000","ML","PN","375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BEVACIZUMAB 25 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9035","HCPCS","50242-060-01","NDC","facility","outpatient","1.600000","ML","PN,JZ","375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BEVACIZUMAB 25 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9035","HCPCS","50242-061-01","NDC","facility","outpatient","0.933333","ML","PN,JZ","306.25","306.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BEVACIZUMAB 25 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9035","HCPCS","50242-060-01","NDC","facility","outpatient","0.400000","ML","PN","375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BLEOMYCIN SULFATE 15 UNITS IJ SOLR","81000008","CDM","0636","RC","J9040","HCPCS","61703-332-18","NDC","facility","outpatient","1.000000","UN","JZ","393.58","393.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BLEOMYCIN SULFATE 30 UNITS IJ SOLR","81000008","CDM","0636","RC","J9040","HCPCS","63323-137-20","NDC","facility","outpatient","0.500000","UN","JZ","297.50","297.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BORTEZOMIB 3.5 MG IJ SOLR","81000008","CDM","0636","RC","J9041","HCPCS","10019-991-01","NDC","facility","outpatient","0.028572","UN","PN","14.06","14.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BORTEZOMIB 3.5 MG IJ SOLR","81000008","CDM","0636","RC","J9041","HCPCS","10019-991-01","NDC","facility","outpatient","0.100000","ME","PN,JW","2.16","2.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"BORTEZOMIB 3.5 MG IJ SOLR","81000008","CDM","0636","RC","J9041","HCPCS","63020-049-01","NDC","facility","outpatient","0.028572","UN","PN,JZ","274.8","274.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BORTEZOMIB 3.5 MG IJ SOLR","81000008","CDM","0636","RC","J9041","HCPCS","10019-991-01","NDC","facility","outpatient","0.028395","UN","PN,JZ","14.15","14.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BRENTUXIMAB VEDOTIN 50 MG IV SOLR","81000008","CDM","0636","RC","J9042","HCPCS","51144-050-01","NDC","facility","outpatient","0.020000","UN","PN","391.61","391.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BRENTUXIMAB VEDOTIN 50 MG IV SOLR","81000008","CDM","0636","RC","J9042","HCPCS","51144-050-01","NDC","facility","outpatient","1.000000","ME","PN,JW","261.07","261.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"BRENTUXIMAB VEDOTIN 50 MG IV SOLR","81000008","CDM","0636","RC","J9042","HCPCS","51144-050-01","NDC","facility","outpatient","0.020000","UN","PN,JZ","406.87","406.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","0703-4246-01","NDC","facility","outpatient","7.473666","ML",,"179.4","179.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","16729-295-12","NDC","facility","outpatient","5.000000","ML",,"46.60","46.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","55150-335-01","NDC","facility","outpatient","6.411111","ML",,"33.99","33.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","55150-386-01","NDC","facility","outpatient","4.853846","ML",,"31.68","31.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","61703-339-50","NDC","facility","outpatient","6.753240","ML",,"120","120",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","61703-339-56","NDC","facility","outpatient","8.754200","ML",,"120","120",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","0703-4239-01","NDC","facility","outpatient","5.262099","ML","PN","42.44","42.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","50742-447-45","NDC","facility","outpatient","4.886800","ML","PN","171.27","171.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","54288-165-01","NDC","facility","outpatient","5.000000","ML","PN","70.75","70.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","55150-335-01","NDC","facility","outpatient","4.797937","ML","PN","37.66","37.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","55150-386-01","NDC","facility","outpatient","4.769886","ML","PN","31.81","31.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","61703-339-18","NDC","facility","outpatient","3.400000","ML","PN","76.54","76.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","61703-339-56","NDC","facility","outpatient","4.850548","ML","PN","40.54","40.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARBOPLATIN 450 MG/45ML IV SOLN","81000008","CDM","0636","RC","J9045","HCPCS","0703-4239-01","NDC","facility","outpatient","3.896600","ML",,"89.73","89.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CARFILZOMIB 30 MG IV SOLR","81000008","CDM","0636","RC","J9047","HCPCS","76075-102-01","NDC","facility","outpatient","0.032644","UN","PN","258.62","258.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARFILZOMIB 30 MG IV SOLR","81000008","CDM","0636","RC","J9047","HCPCS","76075-102-01","NDC","facility","outpatient","1.600000","ME","PN,JW","95.34","95.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"CARFILZOMIB 60 MG IV SOLR","81000008","CDM","0636","RC","J9047","HCPCS","76075-101-01","NDC","facility","outpatient","0.016666","UN","PN,JZ","112.5","112.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CARFILZOMIB 30 MG IV SOLR","81000008","CDM","0636","RC","J9047","HCPCS","76075-102-01","NDC","facility","outpatient","0.032644","UN","PN,JZ","258.62","258.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CARFILZOMIB 10 MG IV SOLR","81000008","CDM","0636","RC","J9047","HCPCS","76075-103-01","NDC","facility","outpatient","0.100000","UN","PN,JZ","297.92","297.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CETUXIMAB 100 MG/50ML IV SOLN","81000008","CDM","0636","RC","J9055","HCPCS","66733-958-23","NDC","facility","outpatient","5.000000","ML","JZ","225","225",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CETUXIMAB 100 MG/50ML IV SOLN","81000008","CDM","0636","RC","J9055","HCPCS","66733-948-23","NDC","facility","outpatient","5.000000","ML","JZ","520","520",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9060","HCPCS","0143-9504-01","NDC","facility","outpatient","9.644444","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9060","HCPCS","16729-288-11","NDC","facility","outpatient","9.604545","ML","PN","46.64","46.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9060","HCPCS","25021-253-51","NDC","facility","outpatient","9.144868","ML","PN","46.48","46.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9060","HCPCS","63323-103-51","NDC","facility","outpatient","8.351059","ML","PN","71.02","71.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CISPLATIN 1 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9060","HCPCS","63323-103-65","NDC","facility","outpatient","9.207241","ML","PN","52.89","52.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"AMIVANTAMAB-VMJW 350 MG/7ML IV SOLN","81000008","CDM","0636","RC","J9061","HCPCS","57894-501-01","NDC","facility","outpatient","0.040000","ML","PN,JZ","48.45","48.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MIRVETUXIMAB SORAVTANSINE-GYNX 100 MG/20ML IV SOLN","81000008","CDM","0636","RC","J9063","HCPCS","72903-853-01","NDC","facility","outpatient","0.200786","ML","PN,JW","75.82","75.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"MIRVETUXIMAB SORAVTANSINE-GYNX 100 MG/20ML IV SOLN","81000008","CDM","0636","RC","J9063","HCPCS","72903-853-01","NDC","facility","outpatient","0.199965","ML","PN,JZ","113.09","113.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MIRVETUXIMAB SORAVTANSINE-GYNX 100 MG/20ML IV SOLN","81000008","CDM","0636","RC","J9063","HCPCS","72903-853-01","NDC","facility","outpatient","0.199936","ML","PN","112.91","112.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9070","HCPCS","10019-956-01","NDC","facility","outpatient","0.096626","UN","PN,JZ","525.08","525.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9070","HCPCS","10019-955-01","NDC","facility","outpatient","0.184571","UN","PN,JZ","527.27","527.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9070","HCPCS","10019-956-01","NDC","facility","outpatient","114.729787","ME","PN,JW","105.19","105.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9070","HCPCS","10019-956-01","NDC","facility","outpatient","0.095475","UN","PN","520.86","520.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CYCLOPHOSPHAMIDE 500 MG/2.5ML IV SOLN","81000008","CDM","0636","RC","J9070","HCPCS","70860-218-10","NDC","facility","outpatient","1.500000","ML",,"722.29","722.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","65219-135-20","NDC","facility","outpatient","0.009937","UN","PN,JZ","13.95","13.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","10019-955-01","NDC","facility","outpatient","0.009857","UN","PN","28.16","28.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","10019-956-01","NDC","facility","outpatient","0.004993","UN","PN","26.13","26.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","25021-248-51","NDC","facility","outpatient","0.004978","UN","PN","9.82","9.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","65219-135-20","NDC","facility","outpatient","0.009965","UN","PN","14.02","14.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","10019-955-01","NDC","facility","outpatient","0.251388","ML","PN,JW","4.42","4.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","10019-956-01","NDC","facility","outpatient","0.251271","ML","PN,JW","4.42","4.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","25021-248-51","NDC","facility","outpatient","0.253834","ML","PN,JW","1.54","1.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","65219-131-20","NDC","facility","outpatient","0.252366","ML","PN,JW","2.18","2.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","65219-135-20","NDC","facility","outpatient","0.253068","ML","PN,JW","2.19","2.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 500 MG/25ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","10019-955-01","NDC","facility","outpatient","0.009970","UN","PN,JZ","26.12","26.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","10019-956-01","NDC","facility","outpatient","0.004993","UN","PN,JZ","22.36","22.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","25021-248-51","NDC","facility","outpatient","0.004995","UN","PN,JZ","9.86","9.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","65219-131-20","NDC","facility","outpatient","0.004997","UN","PN,JZ","13.99","13.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYCLOPHOSPHAMIDE 1000 MG/50ML IJ (WET SOLR VIAL)","81000008","CDM","0636","RC","J9075","HCPCS","65219-131-20","NDC","facility","outpatient","0.004990","UN","PN","13.98","13.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CYTARABINE (PF) 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J9100","HCPCS","61703-319-22","NDC","facility","outpatient","0.997959","ML","JZ","7.91","7.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CYTARABINE (PF) 100 MG/ML IJ SOLN","81000008","CDM","0636","RC","J9100","HCPCS","63323-120-20","NDC","facility","outpatient","0.997959","ML",,"8.13","8.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CYTARABINE 20MG/ML CHEMO IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0636","RC","J9100","HCPCS","61703-305-38","NDC","facility","outpatient","8.333333","ML","JZ","575.84","575.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML IV SOLN","81000008","CDM","0636","RC","J9118","HCPCS","72694-515-01","NDC","facility","outpatient","0.016451","ML","JZ","129.81","129.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DACARBAZINE 200 MG IV SOLR","81000008","CDM","0636","RC","J9130","HCPCS","0143-9245-10","NDC","facility","outpatient","0.500000","UN","PN,JZ","52.44","52.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DACARBAZINE 100 MG IV SOLR","81000008","CDM","0636","RC","J9130","HCPCS","63323-127-10","NDC","facility","outpatient","1.000000","UN","PN,JZ","122.06","122.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DARATUMUMAB-HYALURONIDASE-FIHJ 1800-30000 MG-UT/15ML SC SOLN","81000008","CDM","0636","RC","J9144","HCPCS","57894-503-01","NDC","facility","outpatient","0.088983","ML","PN,JZ","95.41","95.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DARATUMUMAB-HYALURONIDASE-FIHJ 1800-30000 MG-UT/15ML SC SOLN","81000008","CDM","0636","RC","J9144","HCPCS","57894-503-01","NDC","facility","outpatient","0.083333","ML","PN","91.19","91.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 20 MG/2ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","0409-0201-02","NDC","facility","outpatient","0.099247","ML","PN","24.45","24.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 80 MG/8ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","0409-0201-10","NDC","facility","outpatient","0.117826","ML","PN","23.21","23.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 160 MG/8ML IV CONC","81000008","CDM","0636","RC","J9171","HCPCS","0409-0367-01","NDC","facility","outpatient","0.049955","ML","PN","27.19","27.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 160 MG/8ML IV CONC","81000008","CDM","0636","RC","J9171","HCPCS","45963-734-54","NDC","facility","outpatient","0.049722","ML","PN","77.57","77.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 20 MG/2ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","62332-678-02","NDC","facility","outpatient","0.097777","ML","PN","123.49","123.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 20 MG/2ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","66758-050-01","NDC","facility","outpatient","0.099731","ML","PN","109.66","109.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 80 MG/8ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","67457-532-08","NDC","facility","outpatient","0.099981","ML","PN","26.81","26.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 160 MG/8ML IV CONC","81000008","CDM","0636","RC","J9171","HCPCS","67457-781-08","NDC","facility","outpatient","0.050000","ML","PN","63.90","63.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 80 MG/8ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","71288-144-08","NDC","facility","outpatient","0.100000","ML","PN","15.6","15.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOCETAXEL 20 MG/2ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","0409-0201-02","NDC","facility","outpatient","1.039543","ME","PN,JW","3.31","3.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DOCETAXEL 160 MG/8ML IV CONC","81000008","CDM","0636","RC","J9171","HCPCS","45963-734-54","NDC","facility","outpatient","0.054444","ML","PN,JW","13.07","13.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DOCETAXEL 20 MG/2ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","62332-678-02","NDC","facility","outpatient","1.018181","ME","PN,JW","19.78","19.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DOCETAXEL 20 MG/2ML IV SOLN","81000008","CDM","0636","RC","J9171","HCPCS","0409-0201-02","NDC","facility","outpatient","0.130081","ML","PN,JZ","27.17","27.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOCETAXEL 160 MG/8ML IV CONC","81000008","CDM","0636","RC","J9171","HCPCS","45963-734-54","NDC","facility","outpatient","0.050000","ML","PN,JZ","78","78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DURVALUMAB 500 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9173","HCPCS","0310-4611-50","NDC","facility","outpatient","1.248000","ML","PN","236.84","236.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DURVALUMAB 500 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9173","HCPCS","0310-4611-50","NDC","facility","outpatient","0.204800","ML","PN,JW","101.45","101.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DURVALUMAB 500 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9173","HCPCS","0310-4611-50","NDC","facility","outpatient","0.205077","ML","PN,JZ","146.01","146.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ERIBULIN 0.5MG/ML CHEMO IV PUSH","81000008","CDM","0636","RC","J9179","HCPCS","62856-389-01","NDC","facility","outpatient","0.200000","ML","PN,JZ","592.2","592.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9181","HCPCS","63323-104-25","NDC","facility","outpatient","0.480175","ML","PN","15.79","15.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9181","HCPCS","63323-104-06","NDC","facility","outpatient","0.478947","ML","PN","15.79","15.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ETOPOSIDE 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9181","HCPCS","16729-114-31","NDC","facility","outpatient","0.482517","ML","PN","16.78","16.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","63323-117-20","NDC","facility","outpatient","6.500000","ML","JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","16729-276-38","NDC","facility","outpatient","8.625000","ML","PN","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","25021-215-98","NDC","facility","outpatient","7.857142","ML","PN","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","62332-751-50","NDC","facility","outpatient","7.000000","ML","PN","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","16729-276-38","NDC","facility","outpatient","10.916666","ML","PN,JW","7.51","7.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","25021-215-98","NDC","facility","outpatient","11.428571","ML","PN,JW","7.67","7.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","62332-751-50","NDC","facility","outpatient","12.000000","ML","PN,JW","8.24","8.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","16729-276-38","NDC","facility","outpatient","8.625000","ML","PN,JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","16729-276-68","NDC","facility","outpatient","7.111111","ML","PN,JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","25021-215-98","NDC","facility","outpatient","8.000000","ML","PN,JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","62332-751-50","NDC","facility","outpatient","8.312500","ML","PN,JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","63323-117-10","NDC","facility","outpatient","9.456156","ML","PN,JZ","4.71","4.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FLUOROURACIL 50 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9190","HCPCS","63323-117-20","NDC","facility","outpatient","7.876993","ML","PN,JZ","149.04","149.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 GM/10ML IV SOLN","81000008","CDM","0636","RC","J9196","HCPCS","16729-419-03","NDC","facility","outpatient","2.000000","ML","JZ","102.96","102.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 GM/10ML IV SOLN","81000008","CDM","0636","RC","J9196","HCPCS","16729-419-03","NDC","facility","outpatient","3.142857","ML",,"102.96","102.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GEMCITABINE HCL 200 MG/2ML IV SOLN","81000008","CDM","0636","RC","J9196","HCPCS","16729-391-30","NDC","facility","outpatient","1.954761","ML","PN","332.55","332.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 1 GM/10ML IV SOLN","81000008","CDM","0636","RC","J9196","HCPCS","16729-419-03","NDC","facility","outpatient","2.029377","ML","PN","96.96","96.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 1.5 GM/15ML IV SOLN","81000008","CDM","0636","RC","J9196","HCPCS","16729-423-33","NDC","facility","outpatient","1.900450","ML","PN","80.89","80.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 2 GM/20ML IV SOLN","81000008","CDM","0636","RC","J9196","HCPCS","16729-426-05","NDC","facility","outpatient","1.996551","ML","PN","88.95","88.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 200 MG IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","25021-234-10","NDC","facility","outpatient","175.000000","ME","PN","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","25021-235-50","NDC","facility","outpatient","0.200000","UN","PN","77.45","77.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","25021-235-51","NDC","facility","outpatient","0.200000","UN","PN","77.45","77.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 200 MG IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","71288-113-10","NDC","facility","outpatient","187.500000","ME","PN","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 1000 MG/26.3ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9201","HCPCS","71288-114-50","NDC","facility","outpatient","0.198000","UN","PN","70.94","70.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 200 MG/5.26ML IV SOLN","81000008","CDM","0636","RC","J9201","HCPCS","71288-117-06","NDC","facility","outpatient","136.000000","ME","PN","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","25021-235-50","NDC","facility","outpatient","200.000000","ME","PN,JW","11.92","11.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","25021-235-51","NDC","facility","outpatient","200.000000","ME","PN,JW","11.92","11.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1000 MG/26.3ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9201","HCPCS","71288-114-50","NDC","facility","outpatient","5.417800","ML","PN,JW","11.35","11.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","16714-930-01","NDC","facility","outpatient","0.200000","UN","PN,JZ","77.82","77.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 200 MG IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","25021-234-10","NDC","facility","outpatient","0.937500","UN","PN,JZ","114.97","114.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","25021-235-50","NDC","facility","outpatient","0.200000","UN","PN,JZ","77.45","77.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","25021-235-51","NDC","facility","outpatient","0.200000","UN","PN,JZ","77.45","77.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","70860-205-50","NDC","facility","outpatient","0.200000","UN","PN,JZ","70.2","70.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 200 MG IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","71288-113-10","NDC","facility","outpatient","0.988875","UN","PN,JZ","139.19","139.19",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 G IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","0409-0186-01","NDC","facility","outpatient","0.200000","GM","PN","79.22","79.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 200 MG IV SOLR","81000008","CDM","0636","RC","J9201","HCPCS","0409-0185-01","NDC","facility","outpatient","200.000000","ME","PN","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 200 MG/5.26ML IV SOLN","81000008","CDM","0636","RC","J9201","HCPCS","0409-0183-01","NDC","facility","outpatient","200.000000","ME","PN","112.78","112.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"GEMCITABINE HCL 1000 MG/26.3ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9201","HCPCS","71288-114-50","NDC","facility","outpatient","0.200000","UN","PN,JZ","71.66","71.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 GM/26.3ML IV SOLN","81000008","CDM","0636","RC","J9201","HCPCS","0409-0181-01","NDC","facility","outpatient","6.762857","ML","JZ","70.67","70.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 1 GM/26.3ML IV SOLN","81000008","CDM","0636","RC","J9201","HCPCS","71288-117-28","NDC","facility","outpatient","5.260000","ML","JZ","60","60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GEMCITABINE HCL 200 MG/5.26ML IV SOLN","81000008","CDM","0636","RC","J9201","HCPCS","71288-117-06","NDC","facility","outpatient","5.002773","ML","PN,JZ","82.07","82.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GOSERELIN ACETATE 10.8 MG SC IMPL","81000008","CDM","0636","RC","J9202","HCPCS","70720-951-30","NDC","facility","outpatient","0.333333","UN","PN,JZ","3836.40","3836.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GOSERELIN ACETATE 3.6 MG SC IMPL","81000008","CDM","0636","RC","J9202","HCPCS","70720-950-36","NDC","facility","outpatient","1.341463","UN","PN,JZ","5433.30","5433.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL LIPOSOME 43 MG/10ML IV INJ","81000008","CDM","0636","RC","J9205","HCPCS","15054-0043-1","NDC","facility","outpatient","0.230392","ML","PN","178.00","178.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IRINOTECAN HCL LIPOSOME 43 MG/10ML IV INJ","81000008","CDM","0636","RC","J9205","HCPCS","15054-0043-1","NDC","facility","outpatient","0.239382","ML","PN,JW","79.47","79.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"IRINOTECAN HCL LIPOSOME 43 MG/10ML IV INJ","81000008","CDM","0636","RC","J9205","HCPCS","15054-0043-1","NDC","facility","outpatient","0.232087","ML","PN,JZ","168.22","168.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","61703-349-09","NDC","facility","outpatient","1.000000","ML","PN,JZ","35.49","35.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","60505-6128-0","NDC","facility","outpatient","0.933571","ML","PN","57.02","57.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","60505-6128-1","NDC","facility","outpatient","0.997222","ML","PN","46.50","46.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","60505-6128-0","NDC","facility","outpatient","1.093000","ML","PN,JW","9.54","9.54",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","60505-6128-1","NDC","facility","outpatient","1.025000","ML","PN,JW","7.76","7.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","61703-349-09","NDC","facility","outpatient","1.680000","ML","PN,JW","8.86","8.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","0009-7529-03","NDC","facility","outpatient","1.000000","ML","PN,JZ","64.38","64.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","0143-9701-01","NDC","facility","outpatient","0.997136","ML","PN,JZ","97.09","97.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","60505-6128-0","NDC","facility","outpatient","0.944568","ML","PN,JZ","56.95","56.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","60505-6128-1","NDC","facility","outpatient","0.999191","ML","PN,JZ","46.96","46.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IRINOTECAN HCL 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9206","HCPCS","61703-349-09","NDC","facility","outpatient","0.924444","ML","PN","34.12","34.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SC KIT","81000008","CDM","0636","RC","J9217","HCPCS","62935-227-10","NDC","facility","outpatient","0.666666","UN","PN,JZ","2500","2500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUPROLIDE ACETATE (6 MONTH) 45 MG SC KIT","81000008","CDM","0636","RC","J9217","HCPCS","62935-453-45","NDC","facility","outpatient","0.166666","UN","PN,JZ","1897.09","1897.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LEUPROLIDE ACETATE (6 MONTH) 45 MG SC KIT","81000008","CDM","0636","RC","J9217","HCPCS","62935-461-50","NDC","facility","outpatient","0.166666","UN","PN,JZ","1897.09","1897.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"LURBINECTEDIN 4 MG IV SOLR","81000008","CDM","0636","RC","J9223","HCPCS","68727-712-01","NDC","facility","outpatient","0.024791","UN","PN,JZ","349.41","349.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IPILIMUMAB 50 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9228","HCPCS","0003-2328-22","NDC","facility","outpatient","0.200000","ML","PN,JZ","301.15","301.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IPILIMUMAB 50 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9228","HCPCS","0003-2327-11","NDC","facility","outpatient","0.200000","ML","PN,JZ","306.38","306.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE 25MG/ML CHEMO IV SYRINGE (PEDIATRIC) SH","81000008","CDM","0636","RC","J9255","HCPCS","16729-277-30","NDC","facility","outpatient","2.000000","ML",,"300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9258","HCPCS","0703-3218-01","NDC","facility","outpatient","0.166666","ML","PN","2.6","2.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J9260","HCPCS","0143-9519-10","NDC","facility","outpatient","3.086163","ML","JZ","166.62","166.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM 50 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J9260","HCPCS","61703-350-38","NDC","facility","outpatient","1.775000","ML","JZ","78.41","78.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN","81000008","CDM","0636","RC","J9260","HCPCS","61703-408-41","NDC","facility","outpatient","1.773333","ML","JZ","100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J9260","HCPCS","0143-9519-10","NDC","facility","outpatient","0.480000","ML","PN,JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM 1 G IJ SOLR","81000008","CDM","0636","RC","J9260","HCPCS","0143-9830-01","NDC","facility","outpatient","0.049722","UN","PN,JZ","33.33","33.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM 50 MG/2ML IJ SOLN","81000008","CDM","0636","RC","J9260","HCPCS","61703-350-38","NDC","facility","outpatient","1.500000","ML","PN,JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHOTREXATE SODIUM 250 MG/10ML IJ SOLN","81000008","CDM","0636","RC","J9260","HCPCS","63323-123-10","NDC","facility","outpatient","0.600000","ML","JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","25021-233-20","NDC","facility","outpatient","0.100000","ML","PN","1.97","1.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","60505-6132-6","NDC","facility","outpatient","0.125119","ML","PN","4.12","4.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","60505-6132-7","NDC","facility","outpatient","0.102528","ML","PN","3.80","3.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","72603-101-01","NDC","facility","outpatient","0.100000","ML","PN","8.89","8.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","0781-3315-70","NDC","facility","outpatient","0.100000","ML","PN,JW","2.12","2.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","25021-233-20","NDC","facility","outpatient","0.100000","ML","PN,JW","0.3","0.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","60505-6132-6","NDC","facility","outpatient","0.116641","ML","PN,JW","0.6","0.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","60505-6132-7","NDC","facility","outpatient","0.100000","ML","PN,JW","0.59","0.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","72603-101-01","NDC","facility","outpatient","0.100000","ML","PN,JW","1.37","1.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","0781-3315-70","NDC","facility","outpatient","0.100000","ML","PN,JZ","13.79","13.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","25021-233-20","NDC","facility","outpatient","0.100000","ML","PN,JZ","1.95","1.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","60505-6132-6","NDC","facility","outpatient","0.100000","ML","PN,JZ","3.90","3.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","60505-6132-7","NDC","facility","outpatient","0.118448","ML","PN,JZ","3.9","3.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","61703-363-22","NDC","facility","outpatient","0.100000","ML","PN,JZ","3.74","3.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","72603-101-01","NDC","facility","outpatient","0.100000","ML","PN,JZ","8.89","8.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","0781-3315-70","NDC","facility","outpatient","0.100000","ML","PN","13.79","13.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","60505-6132-6","NDC","facility","outpatient","0.100000","ML",,"4.2","4.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OXALIPLATIN 5 MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","J9263","HCPCS","60505-6132-7","NDC","facility","outpatient","0.100000","ML","JZ","3.9","3.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"STUDY RX: INVESTIGATIONAL PACLITAXEL PROTEIN-BOUND 100MG IV SUSR","81000008","CDM","0636","RC","J9264","HCPCS","68817-134-50","NDC","facility","outpatient","0.011372","UN","PN","65.23","65.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"STUDY RX: INVESTIGATIONAL PACLITAXEL PROTEIN-BOUND 100MG IV SUSR","81000008","CDM","0636","RC","J9264","HCPCS","68817-134-50","NDC","facility","outpatient","0.010699","UN","PN,JZ","64.94","64.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"STUDY RX: INVESTIGATIONAL PACLITAXEL PROTEIN-BOUND 100MG IV SUSR","81000008","CDM","0636","RC","J9264","HCPCS","68817-134-50","NDC","facility","outpatient","0.222517","ML","PN,JW","18.98","18.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","70860-200-50","NDC","facility","outpatient","0.166666","ML","PN","3.08","3.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","61703-342-50","NDC","facility","outpatient","0.166621","ML","PN","2.07","2.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","61703-342-22","NDC","facility","outpatient","0.166666","ML","PN","1.90","1.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","25021-255-50","NDC","facility","outpatient","0.183005","ML","PN","1.99","1.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","16714-137-01","NDC","facility","outpatient","0.195410","ML","PN","2.48","2.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","0703-3216-01","NDC","facility","outpatient","1.488118","ML",,"0.22","0.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","25021-255-50","NDC","facility","outpatient","0.166666","ML",,"2.33","2.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","61703-342-22","NDC","facility","outpatient","0.166666","ML",,"0.16","0.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","61703-342-50","NDC","facility","outpatient","0.843559","ML",,"3.18","3.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","63323-763-16","NDC","facility","outpatient","0.164453","ML",,"4.08","4.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","70860-200-17","NDC","facility","outpatient","1.487625","ML",,"0.14","0.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","70860-200-50","NDC","facility","outpatient","0.809721","ML",,"0.10","0.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","0703-3218-01","NDC","facility","outpatient","0.205035","ML","PN","2.64","2.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PACLITAXEL 6 MG/ML IV CONC - CONSOLIDATED","81000008","CDM","0636","RC","J9267","HCPCS","25021-255-17","NDC","facility","outpatient","0.166455","ML",,"3.00","3.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PEMBROLIZUMAB 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9271","HCPCS","0006-3026-02","NDC","facility","outpatient","0.120000","ML","JZ","41.29","41.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMBROLIZUMAB 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9271","HCPCS","0006-3026-02","NDC","facility","outpatient","0.400902","ML","PN","91.61","91.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PEMBROLIZUMAB 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9271","HCPCS","0006-3026-02","NDC","facility","outpatient","1.000000","ME","PN,JW","66.69","66.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"PEMBROLIZUMAB 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9271","HCPCS","0006-3026-02","NDC","facility","outpatient","0.041077","ML","PN,JZ","101.22","101.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMBROLIZUMAB 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9271","HCPCS","0006-3026-04","NDC","facility","outpatient","0.040000","ML","PN,JZ","50.02","50.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOSTARLIMAB-GXLY 500 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9272","HCPCS","0173-0898-03","NDC","facility","outpatient","0.200000","ML","PN,JZ","411.39","411.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TEBENTAFUSP-TEBN 100 MCG/0.5ML IV SOLN","81000008","CDM","0636","RC","J9274","HCPCS","80446-401-01","NDC","facility","outpatient","0.005000","ML","PN","364.02","364.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TEBENTAFUSP-TEBN 100 MCG/0.5ML IV SOLN","81000008","CDM","0636","RC","J9274","HCPCS","80446-401-01","NDC","facility","outpatient","1","EA","PN,JW","242.68","242.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | NDC EA = 1.000000 MCG | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"TEBENTAFUSP-TEBN 100 MCG/0.5ML IV SOLN","81000008","CDM","0636","RC","J9274","HCPCS","80446-401-01","NDC","facility","outpatient","0.005000","ML","PN,JZ","364.68","364.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MITOMYCIN 5MG IV SOLR CHEMO (PF) FOR OPHTH USE","81000008","CDM","0636","RC","J9280","HCPCS","72819-152-05","NDC","facility","outpatient","0.040000","UN","JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MITOMYCIN 5MG IV SOLR CHEMO (PF) FOR OPHTH USE","81000008","CDM","0636","RC","J9280","HCPCS","16729-115-05","NDC","facility","outpatient","1.647368","UN","PN,JZ","1374.37","1374.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"MITOMYCIN 5MG IV SOLR CHEMO (PF) FOR OPHTH USE","81000008","CDM","0636","RC","J9280","HCPCS","71288-137-20","NDC","facility","outpatient","0.815000","UN","PN,JZ","1233.92","1233.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML IV SOLN","81000008","CDM","0636","RC","J9298","HCPCS","0003-7125-11","NDC","facility","outpatient","0.250000","ML","PN","326.98","326.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML IV SOLN","81000008","CDM","0636","RC","J9298","HCPCS","0003-7125-11","NDC","facility","outpatient","0.265810","ML","PN,JZ","325.96","325.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NIVOLUMAB 40 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9299","HCPCS","0003-3772-11","NDC","facility","outpatient","0.100000","ML","PN","128.42","128.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NIVOLUMAB 40 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9299","HCPCS","0003-3772-11","NDC","facility","outpatient","0.100000","ML","PN,JW","36.69","36.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"NIVOLUMAB 240 MG/24ML IV SOLN","81000008","CDM","0636","RC","J9299","HCPCS","0003-3734-13","NDC","facility","outpatient","0.105925","ML","PN,JZ","56.92","56.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NIVOLUMAB 40 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9299","HCPCS","0003-3772-11","NDC","facility","outpatient","0.100000","ML","PN,JZ","129.70","129.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OBINUTUZUMAB 1000 MG/40ML IV SOLN","81000008","CDM","0636","RC","J9301","HCPCS","50242-070-01","NDC","facility","outpatient","0.400000","ML","PN,JZ","170.18","170.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PANITUMUMAB 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9303","HCPCS","55513-956-01","NDC","facility","outpatient","0.500000","ML","PN","392.86","392.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PANITUMUMAB 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9303","HCPCS","55513-956-01","NDC","facility","outpatient","0.500000","ML","PN,JW","197.75","197.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"PANITUMUMAB 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9303","HCPCS","55513-954-01","NDC","facility","outpatient","0.500000","ML","PN,JZ","346.07","346.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PANITUMUMAB 100 MG/5ML IV SOLN","81000008","CDM","0636","RC","J9303","HCPCS","55513-956-01","NDC","facility","outpatient","0.500000","ML","PN,JZ","348.03","348.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9305","HCPCS","71288-167-50","NDC","facility","outpatient","0.021960","UN","PN,JZ","23.35","23.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 100 MG IV SOLR","81000008","CDM","0636","RC","J9305","HCPCS","71288-166-10","NDC","facility","outpatient","0.099949","UN","PN,JZ","23.37","23.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9305","HCPCS","71288-167-50","NDC","facility","outpatient","0.466666","ML","PN,JW","4.2","4.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"PEMETREXED DISODIUM 100 MG IV SOLR","81000008","CDM","0636","RC","J9305","HCPCS","71288-166-10","NDC","facility","outpatient","0.098608","UN","PN","24.14","24.14",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9305","HCPCS","71288-167-50","NDC","facility","outpatient","0.019896","UN","PN","23.28","23.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PEMETREXED DISODIUM 100 MG IV SOLR","81000008","CDM","0636","RC","J9305","HCPCS","71288-166-10","NDC","facility","outpatient","0.528000","ML","PN,JW","4.75","4.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"PERTUZUMAB 420 MG/14ML IV SOLN","81000008","CDM","0636","RC","J9306","HCPCS","50242-145-01","NDC","facility","outpatient","0.036986","ML","PN,JZ","30.41","30.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RAMUCIRUMAB 100 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9308","HCPCS","0002-7669-01","NDC","facility","outpatient","0.496000","ML","PN","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"RAMUCIRUMAB 500 MG/50ML IV SOLN","81000008","CDM","0636","RC","J9308","HCPCS","0002-7678-01","NDC","facility","outpatient","0.496916","ML","PN","149.77","149.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"RAMUCIRUMAB 100 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9308","HCPCS","0002-7669-01","NDC","facility","outpatient","0.536000","ML","PN,JW","91.86","91.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"RAMUCIRUMAB 500 MG/50ML IV SOLN","81000008","CDM","0636","RC","J9308","HCPCS","0002-7678-01","NDC","facility","outpatient","0.530434","ML","PN,JW","90.91","90.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"RAMUCIRUMAB 100 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9308","HCPCS","0002-7669-01","NDC","facility","outpatient","0.500000","ML","PN,JZ","297.02","297.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RAMUCIRUMAB 500 MG/50ML IV SOLN","81000008","CDM","0636","RC","J9308","HCPCS","0002-7678-01","NDC","facility","outpatient","0.499741","ML","PN,JZ","140.65","140.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"POLATUZUMAB VEDOTIN-PIIQ 140 MG IV SOLR","81000008","CDM","0636","RC","J9309","HCPCS","50242-105-01","NDC","facility","outpatient","1.045882","ME","PN,JW","148.37","148.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"RITUXIMAB 100 MG/10ML IV SOLN","81000008","CDM","0636","RC","J9312","HCPCS","50242-051-21","NDC","facility","outpatient","1.000000","ML","PN,JZ","167.05","167.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB 500 MG/50ML IV SOLN","81000008","CDM","0636","RC","J9312","HCPCS","50242-053-06","NDC","facility","outpatient","1.000000","ML","PN,JZ","270","270",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PERTUZ-TRASTUZ-HYALURON-ZZXF 60-60-2000 MG-MG-U/ML SC SOLN","81000008","CDM","0636","RC","J9316","HCPCS","50242-260-01","NDC","facility","outpatient","0.125968","ML","PN","127.46","127.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PERTUZ-TRASTUZ-HYALURON-ZZXF 60-60-2000 MG-MG-U/ML SC SOLN","81000008","CDM","0636","RC","J9316","HCPCS","50242-260-01","NDC","facility","outpatient","0.083333","ML","PN,JZ","128.34","128.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SACITUZUMAB GOVITECAN-HZIY 180 MG/18ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9317","HCPCS","55135-132-01","NDC","facility","outpatient","0.013870","UN","PN","81.33","81.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"SACITUZUMAB GOVITECAN-HZIY 180 MG/18ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9317","HCPCS","55135-132-01","NDC","facility","outpatient","0.251123","ML","PN,JW","40.27","40.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"SACITUZUMAB GOVITECAN-HZIY 180 MG/18ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9317","HCPCS","55135-132-01","NDC","facility","outpatient","0.013850","UN","PN,JZ","82.82","82.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TEMSIROLIMUS 25 MG/ML IV SOLN","81000008","CDM","0636","RC","J9330","HCPCS","0008-1179-01","NDC","facility","outpatient","0.040000","ML","PN,JZ","336.05","336.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TOPOTECAN HCL 4 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9351","HCPCS","0409-0302-01","NDC","facility","outpatient","0.099780","ML","PN","13.48","13.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TOPOTECAN HCL 4 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9351","HCPCS","0409-0302-01","NDC","facility","outpatient","0.100689","ME","PN,JW","2.09","2.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"TOPOTECAN HCL 4 MG/4ML IV SOLN","81000008","CDM","0636","RC","J9351","HCPCS","0409-0302-01","NDC","facility","outpatient","0.099920","ML","PN,JZ","13.50","13.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TOPOTECAN HCL 4 MG IV SOLR","81000008","CDM","0636","RC","J9351","HCPCS","16729-151-31","NDC","facility","outpatient","0.025000","UN","PN,JZ","58.22","58.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADO-TRASTUZUMAB EMTANSINE 160 MG/8ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9354","HCPCS","50242-087-01","NDC","facility","outpatient","0.006235","UN","PN","85.25","85.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ADO-TRASTUZUMAB EMTANSINE 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9354","HCPCS","50242-088-01","NDC","facility","outpatient","0.009974","UN","PN","102.96","102.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ADO-TRASTUZUMAB EMTANSINE 160 MG/8ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9354","HCPCS","50242-087-01","NDC","facility","outpatient","0.050281","ML","PN,JW","47.10","47.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"ADO-TRASTUZUMAB EMTANSINE 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9354","HCPCS","50242-088-01","NDC","facility","outpatient","0.050450","ML","PN,JW","47.25","47.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"ADO-TRASTUZUMAB EMTANSINE 160 MG/8ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9354","HCPCS","50242-087-01","NDC","facility","outpatient","0.006249","UN","PN,JZ","85.25","85.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ADO-TRASTUZUMAB EMTANSINE 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9354","HCPCS","50242-088-01","NDC","facility","outpatient","0.010903","UN","PN,JZ","122.52","122.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRASTUZUMAB 150 MG IV SOLR","81000008","CDM","0636","RC","J9355","HCPCS","50242-132-01","NDC","facility","outpatient","0.851069","ML","PN,JW","131.48","131.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"TRASTUZUMAB 150 MG IV SOLR","81000008","CDM","0636","RC","J9355","HCPCS","50242-132-01","NDC","facility","outpatient","0.121728","UN","PN,JZ","279.51","279.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRASTUZUMAB 150 MG IV SOLR","81000008","CDM","0636","RC","J9355","HCPCS","50242-132-01","NDC","facility","outpatient","0.103946","UN","PN","300.20","300.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9358","HCPCS","65597-406-01","NDC","facility","outpatient","0.009991","UN","PN","51.02","51.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9358","HCPCS","65597-406-01","NDC","facility","outpatient","0.050308","ML","PN,JW","32.88","32.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG/5ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","J9358","HCPCS","65597-406-01","NDC","facility","outpatient","0.009995","UN","PN,JZ","50.05","50.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VINBLASTINE SULFATE 1 MG/ML IV SOLN","81000008","CDM","0636","RC","J9360","HCPCS","63323-278-10","NDC","facility","outpatient","0.986603","ML","PN","41.82","41.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"VINCRISTINE SULFATE 1 MG/ML IV SOLN","81000008","CDM","0636","RC","J9370","HCPCS","61703-309-06","NDC","facility","outpatient","1.000000","ML","PN,JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VINCRISTINE SULFATE 1 MG/ML IV SOLN","81000008","CDM","0636","RC","J9370","HCPCS","61703-309-16","NDC","facility","outpatient","0.995500","ML","PN,JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VINCRISTINE SULFATE 1 MG/ML IV SOLN","81000008","CDM","0636","RC","J9370","HCPCS","61703-309-16","NDC","facility","outpatient","2.531333","ML","JZ","106.46","106.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VINCRISTINE SULFATE 1 MG/ML IV SOLN","81000008","CDM","0636","RC","J9370","HCPCS","61703-309-06","NDC","facility","outpatient","1.328750","ML","JZ","155.56","155.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"VINORELBINE TARTRATE 10 MG/ML IV SOLN","81000008","CDM","0636","RC","J9390","HCPCS","25021-204-05","NDC","facility","outpatient","0.840000","ML","PN,JZ","7.39","7.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FULVESTRANT 250 MG/5ML IM SOSY","81000008","CDM","0636","RC","J9395","HCPCS","70860-211-74","NDC","facility","outpatient","0.500000","ML","PN,JZ","260","260",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","44206-310-25","NDC","facility","outpatient","53.174603","ML","JZ","108","108",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","44206-310-50","NDC","facility","outpatient","60.774410","ML","JZ","87.2","87.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","68516-5214-4","NDC","facility","outpatient","77.586206","ML","JZ","55.75","55.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","44206-310-25","NDC","facility","outpatient","50.000000","ML",,"86.4","86.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","44206-310-25","NDC","facility","outpatient","0.500000","ML","PN","250","250",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","44206-310-25","NDC","facility","outpatient","62.375000","ML","PN,JW","26.94","26.94",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","68516-5214-1","NDC","facility","outpatient","62.375000","ML","PN,JW","13.91","13.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","68516-5214-1","NDC","facility","outpatient","0.500000","ML","PN,JZ","250","250",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","68516-5214-5","NDC","facility","outpatient","0.500000","ML","PN,JZ","250","250",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","68516-5214-6","NDC","facility","outpatient","0.500000","ML","PN,JZ","250","250",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 5 % IV SOLN","81000008","CDM","0636","RC","P9041","HCPCS","68516-5214-1","NDC","facility","outpatient","0.500000","ML","PN","250","250",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0636","RC","P9047","HCPCS","0944-0493-02","NDC","facility","outpatient","50.000000","ML","JZ","300","300",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0636","RC","P9047","HCPCS","44206-251-05","NDC","facility","outpatient","57.185628","ML","JZ","540","540",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0636","RC","P9047","HCPCS","44206-251-10","NDC","facility","outpatient","51.638009","ML","JZ","401.83","401.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0636","RC","P9047","HCPCS","68209-643-01","NDC","facility","outpatient","56.666666","ML","JZ","310.05","310.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0636","RC","P9047","HCPCS","68516-5216-1","NDC","facility","outpatient","50.000000","ML","JZ","335.1","335.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ALBUMIN HUMAN 25 % IV SOLN","81000008","CDM","0636","RC","P9047","HCPCS","68516-5216-2","NDC","facility","outpatient","50.000000","ML","JZ","279.25","279.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FERUMOXYTOL 510 MG/17ML IV SOLN","81000008","CDM","0636","RC","Q0138","HCPCS","0781-3154-01","NDC","facility","outpatient","0.033333","ML","PN,JZ","8.52","8.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FOSPHENYTOIN SODIUM 50 MG PE/ML IJ SOLN - CONSOLIDATED","81000008","CDM","0636","RC","Q2009","HCPCS","63323-403-10","NDC","facility","outpatient","1.000000","ML",,"17.64","17.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SIPULEUCEL-T 50000000 CELLS IV SUSP","81000008","CDM","0636","RC","Q2043","HCPCS","30237-8900-6","NDC","facility","outpatient","250.000000","ML","PN","112500","112500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","0338-0063-01","NDC","facility","outpatient","4.971428","ML","JZ","1384.34","1384.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","70710-1531-1","NDC","facility","outpatient","5.000000","ML","PN","1875","1875",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","72603-103-01","NDC","facility","outpatient","4.000000","ML","PN","3023.28","3023.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","70710-1531-1","NDC","facility","outpatient","5.000000","ML","PN,JW","406.99","406.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","72603-103-01","NDC","facility","outpatient","6.000000","ML","PN,JW","697.68","697.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","0338-0067-01","NDC","facility","outpatient","4.835227","ML","PN,JZ","1491.67","1491.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","43598-283-35","NDC","facility","outpatient","4.517000","ML","PN,JZ","1030.12","1030.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","43598-541-25","NDC","facility","outpatient","4.860000","ML","PN,JZ","1458","1458",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","47335-049-40","NDC","facility","outpatient","3.900000","ML","PN,JZ","103.87","103.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","70710-1530-1","NDC","facility","outpatient","4.627333","ML","PN,JZ","1432.55","1432.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","70710-1531-1","NDC","facility","outpatient","4.863636","ML","PN,JZ","1500","1500",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","72603-103-01","NDC","facility","outpatient","4.930555","ML","PN,JZ","2098.69","2098.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ","81000008","CDM","0636","RC","Q2050","HCPCS","0338-0063-01","NDC","facility","outpatient","5.000000","ML","PN,JZ","1875","1875",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY","81000008","CDM","0636","RC","Q5101","HCPCS","61314-318-01","NDC","facility","outpatient","0.001666","ML","JZ","5.49","5.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY","81000008","CDM","0636","RC","Q5101","HCPCS","61314-318-10","NDC","facility","outpatient","0.001666","ML","JZ","5.49","5.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY","81000008","CDM","0636","RC","Q5101","HCPCS","61314-326-01","NDC","facility","outpatient","0.001666","ML","JZ","5.21","5.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY","81000008","CDM","0636","RC","Q5101","HCPCS","61314-326-10","NDC","facility","outpatient","0.001666","ML","JZ","5.21","5.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY","81000008","CDM","0636","RC","Q5101","HCPCS","61314-318-01","NDC","facility","outpatient","0.001666","ML","PN,JZ","5.49","5.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY","81000008","CDM","0636","RC","Q5101","HCPCS","61314-318-10","NDC","facility","outpatient","0.001666","ML","PN,JZ","5.49","5.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLIXIMAB-DYYB 100 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","Q5103","HCPCS","0069-0809-01","NDC","facility","outpatient","0.122641","UN","JZ","199.60","199.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLIXIMAB-DYYB 100 MG/10ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","Q5103","HCPCS","0069-0809-01","NDC","facility","outpatient","0.100000","UN","PN,JZ","259.62","259.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","81000008","CDM","0636","RC","Q5105","HCPCS","0069-1308-10","NDC","facility","outpatient","0.100000","ML","JZ,JB","86.03","86.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JB: Administered subcutaneously"
"EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN (ESRD)","81000008","CDM","0636","RC","Q5106","HCPCS","0069-1309-04","NDC","facility","outpatient","0.025000","ML","PN,JZ,EC","62.5","62.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy"
"EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN (ESRD)","81000008","CDM","0636","RC","Q5106","HCPCS","0069-1309-04","NDC","facility","outpatient","0.025000","ML","PN,JZ","62.5","62.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN","81000008","CDM","0636","RC","Q5107","HCPCS","55513-207-01","NDC","facility","outpatient","0.400000","ML","JZ","125.59","125.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","Q5107","HCPCS","55513-206-01","NDC","facility","outpatient","0.481775","ML","PN","299.88","299.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","Q5107","HCPCS","55513-206-01","NDC","facility","outpatient","0.453170","ML","PN,JW","93.78","93.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN","81000008","CDM","0636","RC","Q5107","HCPCS","55513-207-01","NDC","facility","outpatient","0.424848","ML","PN,JW","88.45","88.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","Q5107","HCPCS","55513-206-01","NDC","facility","outpatient","0.480486","ML","PN,JZ","317.63","317.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN","81000008","CDM","0636","RC","Q5107","HCPCS","55513-207-01","NDC","facility","outpatient","0.461313","ML","PN,JZ","158.76","158.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY","81000008","CDM","0636","RC","Q5108","HCPCS","83257-005-41","NDC","facility","outpatient","0.050000","ML","PN,JZ","583.83","583.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY","81000008","CDM","0636","RC","Q5108","HCPCS","67457-833-06","NDC","facility","outpatient","0.050000","ML","PN,JZ","937.5","937.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY","81000008","CDM","0636","RC","Q5111","HCPCS","70114-101-01","NDC","facility","outpatient","0.050000","ML","PN,JZ","922.07","922.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOAJ","81000008","CDM","0636","RC","Q5111","HCPCS","70114-120-01","NDC","facility","outpatient","0.056015","ML","PN,JZ","1078.70","1078.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRASTUZUMAB-DKST 150 MG IV SOLR","81000008","CDM","0636","RC","Q5114","HCPCS","83257-001-11","NDC","facility","outpatient","0.066111","UN","PN","261.15","261.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TRASTUZUMAB-DKST 150 MG IV SOLR","81000008","CDM","0636","RC","Q5114","HCPCS","83257-001-11","NDC","facility","outpatient","0.492066","ML","PN,JW","77.75","77.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"TRASTUZUMAB-DKST 150 MG IV SOLR","81000008","CDM","0636","RC","Q5114","HCPCS","83257-001-11","NDC","facility","outpatient","0.066420","UN","PN,JZ","262.37","262.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-ABBS 500 MG/50ML IV SOLN","81000008","CDM","0636","RC","Q5115","HCPCS","63459-104-50","NDC","facility","outpatient","1.000000","ML","PN,JZ","225","225",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-ABBS 100 MG/10ML IV SOLN","81000008","CDM","0636","RC","Q5115","HCPCS","63459-103-10","NDC","facility","outpatient","1.000000","ML","PN","375","375",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TRASTUZUMAB-QYYP 150 MG/7.15ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","Q5116","HCPCS","0069-0308-01","NDC","facility","outpatient","0.547109","ML","PN,JW","108.34","108.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"TRASTUZUMAB-QYYP 150 MG/7.15ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","Q5116","HCPCS","0069-0308-01","NDC","facility","outpatient","0.066434","UN","PN,JZ","309.39","309.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRASTUZUMAB-QYYP 150 MG/7.15ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","Q5116","HCPCS","0069-0308-01","NDC","facility","outpatient","0.065551","UN","PN","284.52","284.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TRASTUZUMAB-QYYP 420 MG IV SOLR","81000008","CDM","0636","RC","Q5116","HCPCS","0069-0305-01","NDC","facility","outpatient","0.052606","UN","PN","287.20","287.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TRASTUZUMAB-ANNS 420 MG/20ML IV (WET SOLR VIAL)","81000008","CDM","0636","RC","Q5117","HCPCS","55513-132-01","NDC","facility","outpatient","0.023746","UN","PN","332.31","332.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TRASTUZUMAB-ANNS 150 MG IV SOLR","81000008","CDM","0636","RC","Q5117","HCPCS","55513-141-01","NDC","facility","outpatient","0.066670","UN","PN","519.49","519.49",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TRASTUZUMAB-ANNS 420 MG IV SOLR","81000008","CDM","0636","RC","Q5117","HCPCS","55513-164-01","NDC","facility","outpatient","0.023618","UN","PN","341.69","341.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TRASTUZUMAB-ANNS 150 MG IV SOLR","81000008","CDM","0636","RC","Q5117","HCPCS","55513-141-01","NDC","facility","outpatient","0.476198","ML","PN,JW","108.81","108.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JW: Drug amount discarded/not administered to any patient"
"TRASTUZUMAB-ANNS 150 MG IV SOLR","81000008","CDM","0636","RC","Q5117","HCPCS","55513-141-01","NDC","facility","outpatient","0.085714","UN","PN,JZ","374.48","374.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"BEVACIZUMAB-BVZR 100 MG/4ML IV SOLN","81000008","CDM","0636","RC","Q5118","HCPCS","0069-0315-01","NDC","facility","outpatient","0.400000","ML","PN,JZ","257.63","257.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-PVVR 100 MG/10ML IV SOLN","81000008","CDM","0636","RC","Q5119","HCPCS","0069-0238-01","NDC","facility","outpatient","1.000000","ML","JZ","254.56","254.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-PVVR 500 MG/50ML IV SOLN","81000008","CDM","0636","RC","Q5119","HCPCS","0069-0249-01","NDC","facility","outpatient","1.000000","ML","JZ","137.73","137.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-PVVR 100 MG/10ML IV SOLN","81000008","CDM","0636","RC","Q5119","HCPCS","0069-0238-01","NDC","facility","outpatient","1.066666","ML","PN,JZ","375.26","375.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"RITUXIMAB-PVVR 500 MG/50ML IV SOLN","81000008","CDM","0636","RC","Q5119","HCPCS","0069-0249-01","NDC","facility","outpatient","1.027210","ML","PN,JZ","200.67","200.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INFLIXIMAB-AXXQ 100 MG IV SOLR","81000008","CDM","0636","RC","Q5121","HCPCS","55513-670-01","NDC","facility","outpatient","0.156216","UN","JZ","141.39","141.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FILGRASTIM-AYOW 300 MCG/0.5ML SC SOSY","81000008","CDM","0636","RC","Q5125","HCPCS","70121-1568-1","NDC","facility","outpatient","0.001666","ML","JZ","3.25","3.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SULFUR HEXAFLUORIDE MICROSPH 60.7-25 MG IJ SUSR","81000008","CDM","0636","RC","Q9950","HCPCS","0270-7097-07","NDC","facility","outpatient","0.160000","UN",,"78.09","78.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SULFUR HEXAFLUORIDE MICROSPH 60.7-25 MG IJ SUSR","81000008","CDM","0636","RC","Q9950","HCPCS","0270-7099-16","NDC","facility","outpatient","0.160000","UN",,"76.39","76.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TRYPAN BLUE 0.06 % IO SOSY","81000008","CDM","0636","RC","Q9968","HCPCS","68803-612-10","NDC","facility","outpatient","0.500000","ML","JZ","283.65","283.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"TRYPAN BLUE 0.15 % IO SOSY","81000008","CDM","0636","RC","Q9968","HCPCS","68803-672-05","NDC","facility","outpatient","0.500000","ML",,"695.52","695.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","81000008","CDM","0636","RC","S0020","HCPCS","0409-1159-02","NDC","facility","outpatient","105.000000","ML","JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","S0028","HCPCS","67457-433-22","NDC","facility","outpatient","2.891986","ML","PN,JZ","72.98","72.98",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","S0028","HCPCS","0641-6022-25","NDC","facility","outpatient","2.000000","ML","PN,JZ","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","S0028","HCPCS","67457-433-22","NDC","facility","outpatient","2.000000","ML","JZ","10.07","10.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","S0028","HCPCS","63323-739-12","NDC","facility","outpatient","2.988600","ML","JZ","71.18","71.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"FAMOTIDINE 10MG/ML IV SOLN - CONSOLIDATED","81000008","CDM","0636","RC","S0028","HCPCS","0641-6022-25","NDC","facility","outpatient","2.504383","ML","JZ","68.77","68.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","S0164","HCPCS","0008-0923-55","NDC","facility","outpatient","1.789473","UN",,"61.22","61.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","S0164","HCPCS","0143-9284-10","NDC","facility","outpatient","1.421052","UN",,"60.68","60.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","S0164","HCPCS","25021-751-10","NDC","facility","outpatient","2.153846","UN",,"47.41","47.41",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","81000008","CDM","0636","RC","S0164","HCPCS","55150-202-10","NDC","facility","outpatient","1.666666","UN",,"64.58","64.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MIFEPRISTONE 200 MG PO TABS","81000008","CDM","0636","RC","S0190","HCPCS","64875-001-01","NDC","facility","outpatient","1.000000","UN",,"129","129",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GLUCAGON HCL (RDNA) 1 MG IJ SOLR","81000008","CDM","0636","RC","X6254","HCPCS","0169-7065-15","NDC","facility","outpatient","5.000000","UN",,"10.06","10.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IMMUNE GLOBULIN (HUMAN) 5% IV SOLN - OCTAGAM","81000008","CDM","0636","RC","0069-8451-02","NDC",,,"facility","outpatient","100.000000","ML","PN","3496.8","3496.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN","81000008","CDM","0636","RC","80830-2362-1","NDC",,,"facility","outpatient","50.000000","ML",,"165.9","165.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TOBRAMYCIN 15MG/ML ARTIFICIAL TEARS OPHTH SOLN *COMPOUNDED* SH","81000008","CDM","0636","RC","99999-0032-96","NDC",,,"facility","outpatient","15.000000","ML",,"65","65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALPROSTADIL 500 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J0270","HCPCS","0009-3169-06","NDC","facility","inpatient","0.002500","ML","JZ","2.85","2.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J0630","HCPCS","42023-205-01","NDC","facility","inpatient","1.000000","ML",,"6000","6000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J0630","HCPCS","67457-675-02","NDC","facility","inpatient","1.120000","ML",,"6759.04","6759.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS","81000009","CDM","0250","RC","J0750","HCPCS","0904-7172-07","NDC","facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS","81000009","CDM","0250","RC","J0751","HCPCS","61958-2002-1","NDC","facility","inpatient","1.000000","UN",,"259.1","259.1",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS","81000009","CDM","0250","RC","J0751","HCPCS","61958-2002-2","NDC","facility","inpatient","1.142857","UN",,"263.17","263.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN LISPRO 100 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0024-5926-05","NDC","facility","inpatient","0.032458","ML",,"7.91","7.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP","81000009","CDM","0250","RC","J1815","HCPCS","0002-8315-17","NDC","facility","inpatient","0.045416","ML",,"2.24","2.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0002-8215-17","NDC","facility","inpatient","0.049523","ML",,"2.76","2.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0002-8215-01","NDC","facility","inpatient","0.047653","ML",,"8.78","8.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN LISPRO 100 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0002-7533-01","NDC","facility","inpatient","0.034597","ML",,"7.74","7.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN LISPRO 100 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0002-7510-17","NDC","facility","inpatient","0.030943","ML",,"8.21","8.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN LISPRO 100 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0002-7510-01","NDC","facility","inpatient","0.028234","ML",,"8.40","8.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0002-0213-01","NDC","facility","inpatient","0.055181","ML",,"8.82","8.82",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN GLARGINE 100 UNIT/ML SC SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0088-2220-33","NDC","facility","inpatient","0.047739","ML",,"3.22","3.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0169-1833-11","NDC","facility","inpatient","0.049871","ML",,"1.10","1.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REG HUMAN 100 UNITS/100ML NS IV DRIP GEN MED (PREMIX) SH","81000009","CDM","0250","RC","J1815","HCPCS","0338-0126-12","NDC","facility","inpatient","5.452488","ML",,"0.50","0.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP","81000009","CDM","0250","RC","J1815","HCPCS","0169-1834-11","NDC","facility","inpatient","0.045301","ML",,"3.74","3.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN GLARGINE 100 UNIT/ML SC SOLN","81000009","CDM","0250","RC","J1815","HCPCS","0955-1729-01","NDC","facility","inpatient","0.047147","ML",,"3.27","3.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN","81000009","CDM","0250","RC","J2212","HCPCS","65649-551-02","NDC","facility","inpatient","0.005000","ML","JZ","8.89","8.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN","81000009","CDM","0250","RC","J2212","HCPCS","65649-551-03","NDC","facility","inpatient","0.005000","ML","JZ","8.12","8.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN","81000009","CDM","0250","RC","J2212","HCPCS","65649-551-07","NDC","facility","inpatient","0.005000","ML","JZ","8.21","8.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J2354","HCPCS","25021-463-01","NDC","facility","inpatient","0.559813","ML","JZ","31.29","31.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J2354","HCPCS","63323-376-01","NDC","facility","inpatient","0.262345","ML","JZ","21.03","21.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J2354","HCPCS","63323-377-01","NDC","facility","inpatient","0.052678","ML","JZ","19.38","19.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J2354","HCPCS","0641-6176-10","NDC","facility","inpatient","0.054778","ML","JZ","13.65","13.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J2354","HCPCS","0641-6174-10","NDC","facility","inpatient","0.503208","ML","JZ","30.79","30.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J2354","HCPCS","0078-0181-01","NDC","facility","inpatient","0.250000","ML","JZ","56.25","56.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PAPAVERINE HCL 30 MG/ML IJ SOLN","81000009","CDM","0250","RC","J2440","HCPCS","0517-4002-25","NDC","facility","inpatient","1.921052","ML",,"305.99","305.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PAPAVERINE HCL 30 MG/ML IJ SOLN","81000009","CDM","0250","RC","J2440","HCPCS","14789-121-07","NDC","facility","inpatient","1.000000","ML",,"157.5","157.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN","81000009","CDM","0250","RC","J3030","HCPCS","0143-9638-05","NDC","facility","inpatient","0.500000","ML",,"100.8","100.8",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN","81000009","CDM","0250","RC","J3030","HCPCS","55150-173-01","NDC","facility","inpatient","0.583333","ML","JZ","92.4","92.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J3490","HCPCS","0641-6174-10","NDC","facility","inpatient","0.637931","ML","JZ","28.47","28.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN","81000009","CDM","0250","RC","J3490","HCPCS","25021-463-01","NDC","facility","inpatient","0.852941","ML","JZ","31.28","31.28",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ANAKINRA 100 MG/0.67ML SC SOSY","81000009","CDM","0250","RC","J3490","HCPCS","66658-234-01","NDC","facility","inpatient","0.556615","ML",,"1006.75","1006.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ANAKINRA 100 MG/0.67ML SC SOSY","81000009","CDM","0250","RC","J3490","HCPCS","66658-234-28","NDC","facility","inpatient","0.536000","ML",,"975","975",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN","81000009","CDM","0250","RC","60505-0823-6","NDC",,,"facility","inpatient","11.100000","ML",,"474.16","474.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ABATACEPT 250 MG/10 ML IV (WET SOLR VIAL)","81000009","CDM","0636","RC","J0129","HCPCS","0003-2187-13","NDC","facility","outpatient","0.040000","UN","PN,JZ,JA","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously"
"ABATACEPT 250 MG/10 ML IV (WET SOLR VIAL)","81000009","CDM","0636","RC","J0129","HCPCS","0003-2187-13","NDC","facility","outpatient","0.040000","UN","PN,JA,JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JA: Administered intravenously | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","81000009","CDM","0636","RC","J1815","HCPCS","0002-0213-01","NDC","facility","outpatient","0.250000","ML",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP","81000009","CDM","0636","RC","J1815","HCPCS","0002-8315-17","NDC","facility","outpatient","0.040000","ML",,"3.33","3.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","81000009","CDM","0636","RC","J1815","HCPCS","0169-1833-11","NDC","facility","outpatient","0.077600","ML",,"6.01","6.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN","81000009","CDM","0636","RC","J2354","HCPCS","0641-6176-10","NDC","facility","outpatient","0.150000","ML","JZ","13.65","13.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN","81000009","CDM","0636","RC","J2354","HCPCS","63323-376-01","NDC","facility","outpatient","0.250000","ML","JZ","20.87","20.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PAPAVERINE HCL 30 MG/ML IJ SOLN","81000009","CDM","0636","RC","J2440","HCPCS","0517-4002-25","NDC","facility","outpatient","2.000000","ML",,"323","323",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN","81000009","CDM","0636","RC","J3030","HCPCS","0173-0449-02","NDC","facility","outpatient","0.500000","ML","JZ","873.84","873.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN","81000009","CDM","0636","RC","J3030","HCPCS","55150-173-01","NDC","facility","outpatient","0.500000","ML","JZ","92.4","92.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN","81000009","CDM","0636","RC","J3490","HCPCS","0641-6174-10","NDC","facility","outpatient","0.833333","ML","JZ","18.9","18.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN","81000009","CDM","0636","RC","J3490","HCPCS","25021-463-01","NDC","facility","outpatient","2.500000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"ABATACEPT 250 MG/10 ML IV (WET SOLR VIAL)","81000009","CDM","0637","RC","J0129","HCPCS","0003-2187-13","NDC","facility","outpatient","0.040000","UN","PN,JZ","150","150",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS","81000009","CDM","0637","RC","J0750","HCPCS","0904-7172-07","NDC","facility","outpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS","81000009","CDM","0637","RC","J0751","HCPCS","61958-2002-2","NDC","facility","outpatient","2.000000","UN",,"261.69","261.69",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN LISPRO 100 UNIT/ML IJ SOLN","81000009","CDM","0637","RC","J1815","HCPCS","0002-7510-01","NDC","facility","outpatient","0.027943","ML",,"8.71","8.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN LISPRO 100 UNIT/ML IJ SOLN","81000009","CDM","0637","RC","J1815","HCPCS","0002-7510-17","NDC","facility","outpatient","0.029058","ML",,"8.50","8.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","81000009","CDM","0637","RC","J1815","HCPCS","0002-8215-01","NDC","facility","outpatient","0.057142","ML",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","81000009","CDM","0637","RC","J1815","HCPCS","0002-8215-17","NDC","facility","outpatient","0.052208","ML",,"10","10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN LISPRO 100 UNIT/ML IJ SOLN","81000009","CDM","0637","RC","J1815","HCPCS","0024-5926-05","NDC","facility","outpatient","0.041493","ML",,"6.76","6.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP","81000009","CDM","0637","RC","J1815","HCPCS","0169-1834-11","NDC","facility","outpatient","0.044038","ML",,"3","3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN REG HUMAN 100 UNITS/100ML NS IV DRIP GEN MED (PREMIX) SH","81000009","CDM","0637","RC","J1815","HCPCS","0338-0126-12","NDC","facility","outpatient","5.898876","ML",,"0.5","0.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN GLARGINE 100 UNIT/ML SC SOLN","81000009","CDM","0637","RC","J1815","HCPCS","0955-1729-01","NDC","facility","outpatient","0.030000","ML",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"INSULIN GLARGINE 100 UNIT/ML SC SOLN","81000009","CDM","0637","RC","J1815","HCPCS","0088-2220-33","NDC","facility","outpatient","0.056414","ML",,"4.29","4.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN","81000009","CDM","0637","RC","J2212","HCPCS","65649-551-07","NDC","facility","outpatient","0.005000","ML","JZ","8.27","8.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN","81000009","CDM","0637","RC","J2212","HCPCS","65649-551-02","NDC","facility","outpatient","0.005000","ML","JZ","8.12","8.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN","81000009","CDM","0637","RC","J2354","HCPCS","0641-6174-10","NDC","facility","outpatient","0.574074","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN","81000009","CDM","0637","RC","J2354","HCPCS","25021-463-01","NDC","facility","outpatient","0.500000","ML","JZ","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN","81000009","CDM","0637","RC","J2354","HCPCS","63323-377-01","NDC","facility","outpatient","0.055128","ML","JZ","19.38","19.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN","81000009","CDM","0637","RC","J2354","HCPCS","67457-246-01","NDC","facility","outpatient","0.050000","ML","JZ","15.48","15.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"HCHG SEVOFLURANE","81000010","CDM","250","RC",,,,,"facility","inpatient",,,,"74","74",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SEVOFLURANE","81000010","CDM","250","RC",,,,,"facility","outpatient",,,,"74","74",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESFLURANE","81000011","CDM","250","RC",,,,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DESFLURANE","81000011","CDM","250","RC",,,,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ISOFLURANE","81000012","CDM","250","RC",,,,,"facility","inpatient",,,,"13","13",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ISOFLURANE","81000012","CDM","250","RC",,,,,"facility","outpatient",,,,"13","13",,,,,,,,,,,,,"Gross Charge Type: Standard"
"ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU","81000013","CDM","0250","RC","J7611","HCPCS","0487-9901-30","NDC","facility","inpatient","0.412099","UN",,"3.00","3.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","J7620","HCPCS","76204-600-01","NDC","facility","inpatient","57.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","J7620","HCPCS","60687-405-83","NDC","facility","inpatient","6.193548","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","J7620","HCPCS","0487-0201-01","NDC","facility","inpatient","5.332875","ML",,"14.93","14.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","J7620","HCPCS","0378-9671-30","NDC","facility","inpatient","6.302752","ML",,"14.47","14.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","0378-9671-30","NDC",,,"facility","inpatient","5.185303","ML",,"14.90","14.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","0378-9671-93","NDC",,,"facility","inpatient","3.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","0487-0201-01","NDC",,,"facility","inpatient","4.041450","ML",,"14.96","14.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","60687-405-83","NDC",,,"facility","inpatient","4.418918","ML",,"14.80","14.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0250","RC","76204-600-01","NDC",,,"facility","inpatient","4.609756","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ALBUTEROL SULFATE (5 MG/ML) 0.5% IN NEBU","81000013","CDM","0636","RC","J7611","HCPCS","0487-9901-30","NDC","facility","outpatient","0.487074","UN",,"1.89","1.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0636","RC","J7620","HCPCS","0487-0201-01","NDC","facility","outpatient","5.070552","ML",,"14.01","14.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0636","RC","J7620","HCPCS","0378-9671-30","NDC","facility","outpatient","6.582089","ML",,"13.68","13.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0636","RC","J7620","HCPCS","60687-405-83","NDC","facility","outpatient","5.482758","ML",,"13.37","13.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0636","RC","0378-9671-30","NDC",,,"facility","outpatient","11.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0636","RC","0487-0201-01","NDC",,,"facility","outpatient","19.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","81000013","CDM","0636","RC","60687-405-83","NDC",,,"facility","outpatient","15.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CINACALCET HCL 30 MG PO TABS","81000084","CDM","0250","RC","J0604","HCPCS","16729-440-10","NDC","facility","inpatient","0.033333","UN",,"3.33","3.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU","81000084","CDM","0250","RC","J7614","HCPCS","76204-800-01","NDC","facility","inpatient","1.650000","ML",,"7.5","7.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU","81000084","CDM","0250","RC","J7614","HCPCS","76204-900-01","NDC","facility","inpatient","1.000000","ML",,"5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILDENAFIL CITRATE 20 MG PO TABS","81000084","CDM","0250","RC","S0090","HCPCS","0069-4190-68","NDC","facility","inpatient","0.500000","UN",,"106.92","106.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILDENAFIL CITRATE 20 MG PO TABS","81000084","CDM","0250","RC","S0090","HCPCS","50268-717-15","NDC","facility","inpatient","3.350625","UN",,"50.83","50.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MERCAPTOPURINE 50 MG PO TABS","81000084","CDM","0250","RC","S0108","HCPCS","0054-4581-11","NDC","facility","inpatient","0.875000","UN",,"46.55","46.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MERCAPTOPURINE 50 MG PO TABS","81000084","CDM","0250","RC","S0108","HCPCS","0378-3547-52","NDC","facility","inpatient","0.958333","UN",,"36.67","36.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FINASTERIDE 5 MG PO TABS","81000084","CDM","0250","RC","S0138","HCPCS","60687-428-11","NDC","facility","inpatient","9.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FINASTERIDE 5 MG PO TABS","81000084","CDM","0250","RC","S0138","HCPCS","50268-314-15","NDC","facility","inpatient","2.752212","UN",,"17.2","17.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLISTIMETHATE SODIUM (CBA) 150 MG/2ML IJ (WET SOLR VIAL)","81000084","CDM","0250","RC","S0142","HCPCS","70594-023-01","NDC","facility","inpatient","0.008571","UN",,"1.46","1.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLISTIMETHATE SODIUM (CBA) 150 MG/2ML IJ (WET SOLR VIAL)","81000084","CDM","0250","RC","S0142","HCPCS","70594-023-04","NDC","facility","inpatient","0.006666","UN",,"1.46","1.46",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.5 MCG PO CAPS","81000084","CDM","0250","RC","S0169","HCPCS","0093-7353-01","NDC","facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.25 MCG PO CAPS","81000084","CDM","0250","RC","S0169","HCPCS","60687-345-01","NDC","facility","inpatient","3.342857","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.5 MCG PO CAPS","81000084","CDM","0250","RC","S0169","HCPCS","64380-724-06","NDC","facility","inpatient","10.333333","UN",,"26.27","26.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.5 MCG PO CAPS","81000084","CDM","0250","RC","S0169","HCPCS","69452-208-20","NDC","facility","inpatient","2.000000","UN",,"15.70","15.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ANASTROZOLE 1 MG PO TABS","81000084","CDM","0250","RC","S0170","HCPCS","60687-112-21","NDC","facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEGESTROL ACETATE 40 MG/ML PO SUSP","81000084","CDM","0250","RC","S0179","HCPCS","0121-0945-10","NDC","facility","inpatient","0.500000","ML",,"1.63","1.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TAMOXIFEN CITRATE 20 MG PO TABS","81000084","CDM","0250","RC","S0187","HCPCS","51862-446-01","NDC","facility","inpatient","0.500000","UN",,"20","20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TAMOXIFEN CITRATE 20 MG PO TABS","81000084","CDM","0250","RC","S0187","HCPCS","59651-300-30","NDC","facility","inpatient","0.500000","UN",,"20","20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EXEMESTANE 25 MG PO TABS","81000084","CDM","0250","RC","0009-7663-04","NDC",,,"facility","inpatient","1.000000","UN",,"299.31","299.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 10 MG PO TABS","81000084","CDM","0250","RC","0054-0710-20","NDC",,,"facility","inpatient","1.186379","UN",,"8.68","8.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MERCAPTOPURINE 50 MG PO TABS","81000084","CDM","0250","RC","0054-4581-11","NDC",,,"facility","inpatient","1.000000","UN",,"53.2","53.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 5 MG PO TABS","81000084","CDM","0250","RC","0054-8553-24","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 10 MG PO TABS","81000084","CDM","0250","RC","0054-8554-24","NDC",,,"facility","inpatient","1.000000","UN",,"14.12","14.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILDENAFIL CITRATE 20 MG PO TABS","81000084","CDM","0250","RC","0069-4190-68","NDC",,,"facility","inpatient","1.000000","UN",,"207.01","207.01",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.25 MCG PO CAPS","81000084","CDM","0250","RC","0093-7352-01","NDC",,,"facility","inpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ANASTROZOLE 1 MG PO TABS","81000084","CDM","0250","RC","0093-7536-56","NDC",,,"facility","inpatient","1.000000","UN",,"87.72","87.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEGESTROL ACETATE 40 MG/ML PO SUSP","81000084","CDM","0250","RC","0121-0945-10","NDC",,,"facility","inpatient","13.303303","ML",,"31.91","31.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MERCAPTOPURINE 50 MG PO TABS","81000084","CDM","0250","RC","0378-3547-52","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 5 MG PO TABS","81000084","CDM","0250","RC","0406-5755-23","NDC",,,"facility","inpatient","1.419475","UN",,"30.15","30.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 10 MG PO TABS","81000084","CDM","0250","RC","0406-5771-23","NDC",,,"facility","inpatient","1.087719","UN",,"8.63","8.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEGESTROL ACETATE 20 MG PO TABS","81000084","CDM","0250","RC","0555-0606-02","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EXEMESTANE 25 MG PO TABS","81000084","CDM","0250","RC","0832-0595-30","NDC",,,"facility","inpatient","1.000000","UN",,"131.5","131.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEGESTROL ACETATE 40 MG PO TABS","81000084","CDM","0250","RC","0904-7236-61","NDC",,,"facility","inpatient","1.173913","UN",,"21.05","21.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CINACALCET HCL 30 MG PO TABS","81000084","CDM","0250","RC","16729-440-10","NDC",,,"facility","inpatient","1.081911","UN",,"95.24","95.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CINACALCET HCL 60 MG PO TABS","81000084","CDM","0250","RC","16729-441-10","NDC",,,"facility","inpatient","1.000000","UN",,"183.92","183.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CINACALCET HCL 30 MG PO TABS","81000084","CDM","0250","RC","31722-103-30","NDC",,,"facility","inpatient","1.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FINASTERIDE 5 MG PO TABS","81000084","CDM","0250","RC","31722-525-30","NDC",,,"facility","inpatient","1.000000","UN",,"17.12","17.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EXEMESTANE 25 MG PO TABS","81000084","CDM","0250","RC","47781-108-30","NDC",,,"facility","inpatient","1.000000","UN",,"131.5","131.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEGESTROL ACETATE 20 MG PO TABS","81000084","CDM","0250","RC","49884-289-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FINASTERIDE 5 MG PO TABS","81000084","CDM","0250","RC","50268-314-15","NDC",,,"facility","inpatient","1.279097","UN",,"17.20","17.20",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SILDENAFIL CITRATE 20 MG PO TABS","81000084","CDM","0250","RC","50268-717-15","NDC",,,"facility","inpatient","1.324497","UN",,"50.29","50.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TAMOXIFEN CITRATE 20 MG PO TABS","81000084","CDM","0250","RC","51862-446-01","NDC",,,"facility","inpatient","1.000000","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVOCARNITINE 200 MG/ML IV SOLN","81000084","CDM","0250","RC","54482-147-01","NDC",,,"facility","inpatient","5.000000","ML",,"196.9","196.9",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TAMOXIFEN CITRATE 20 MG PO TABS","81000084","CDM","0250","RC","59651-300-30","NDC",,,"facility","inpatient","1.307692","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"ANASTROZOLE 1 MG PO TABS","81000084","CDM","0250","RC","60687-112-21","NDC",,,"facility","inpatient","1.121212","UN",,"40","40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.25 MCG PO CAPS","81000084","CDM","0250","RC","60687-345-01","NDC",,,"facility","inpatient","1.328042","UN",,"12.55","12.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FINASTERIDE 5 MG PO TABS","81000084","CDM","0250","RC","60687-428-11","NDC",,,"facility","inpatient","1.157894","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CINACALCET HCL 30 MG PO TABS","81000084","CDM","0250","RC","60687-525-11","NDC",,,"facility","inpatient","5.000000","UN",,"100","100",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.5 MCG PO CAPS","81000084","CDM","0250","RC","64380-724-06","NDC",,,"facility","inpatient","1.341463","UN",,"12.26","12.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEGESTROL ACETATE 40 MG/ML PO SUSP","81000084","CDM","0250","RC","66689-020-50","NDC",,,"facility","inpatient","10.000000","ML",,"38.67","38.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 10 MG PO TABS","81000084","CDM","0250","RC","68084-738-01","NDC",,,"facility","inpatient","1.000000","UN",,"15.33","15.33",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"MEGESTROL ACETATE 40 MG/ML PO SUSP","81000084","CDM","0250","RC","68094-250-62","NDC",,,"facility","inpatient","10.000000","ML",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"EXEMESTANE 25 MG PO TABS","81000084","CDM","0250","RC","69097-316-02","NDC",,,"facility","inpatient","1.000000","UN",,"84.7","84.7",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.5 MCG PO CAPS","81000084","CDM","0250","RC","69452-208-20","NDC",,,"facility","inpatient","1.169014","UN",,"13.96","13.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"COLISTIMETHATE SODIUM (CBA) 150 MG/2ML IJ (WET SOLR VIAL)","81000084","CDM","0250","RC","70594-023-01","NDC",,,"facility","inpatient","1.666666","UN",,"117.6","117.6",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU","81000084","CDM","0250","RC","76204-800-01","NDC",,,"facility","inpatient","3.937792","ML",,"13.59","13.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU","81000084","CDM","0250","RC","76204-900-01","NDC",,,"facility","inpatient","3.000000","ML",,"14.74","14.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CINACALCET HCL 30 MG PO TABS","81000084","CDM","0636","RC","J0604","HCPCS","16729-440-10","NDC","facility","outpatient","0.033333","UN",,"3.07","3.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"METHADONE HCL 10 MG PO TABS","81000084","CDM","0636","RC","S0109","HCPCS","0054-0710-20","NDC","facility","outpatient","0.500000","UN",,"3.08","3.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"FINASTERIDE 5 MG PO TABS","81000084","CDM","0636","RC","S0138","HCPCS","50268-314-15","NDC","facility","outpatient","1.000000","UN",,"17.2","17.2",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"CALCITRIOL 0.25 MCG PO CAPS","81000084","CDM","0636","RC","S0169","HCPCS","60687-345-01","NDC","facility","outpatient","1.000000","UN",,"15","15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TPN ADULT CPMC","81000091","CDM","0258","RC","0264-3200-55","NDC",,,"facility","inpatient","668.627946","ML",,"1000","1000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TPN NEONATAL CPMC","81000091","CDM","0258","RC","0264-9341-55","NDC",,,"facility","inpatient","47.050000","ML",,"1000","1000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TPN NEONATAL CPMC","81000091","CDM","0258","RC","0338-0644-03","NDC",,,"facility","inpatient","77.732699","ML",,"1000","1000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"TPN NEONATAL CPMC","81000091","CDM","0258","RC","0409-4192-05","NDC",,,"facility","inpatient","54.527227","ML",,"1000","1000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEONATAL STARTER TPN AA3.5%-DEX10 WITH HEPARIN","81000091","CDM","0258","RC","66647-140-31","NDC",,,"facility","inpatient","250.000000","ML",,"1000","1000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NEONATAL STARTER TPN AA3.5%-DEX10 WITH HEPARIN","81000091","CDM","0258","RC","72196-0431-1","NDC",,,"facility","inpatient","276.881720","ML",,"1000","1000",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","A4217","HCPCS","0338-0003-44","NDC","facility","inpatient","547.619047","ML",,"33.04","33.04",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","A4217","HCPCS","0338-0003-47","NDC","facility","inpatient","1166.666666","ML",,"12.5","12.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","A4217","HCPCS","0338-0004-02","NDC","facility","inpatient","500.000000","ML",,"14.55","14.55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","A4217","HCPCS","0338-0004-03","NDC","facility","inpatient","0.400000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","A4217","HCPCS","0338-0004-04","NDC","facility","inpatient","608.433734","ML",,"36.81","36.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","A4217","HCPCS","50421-00877","NDC","facility","inpatient","0.526315","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE (IO)","81000092","CDM","0250","RC","J3490","HCPCS","0264-1280-55","NDC","facility","inpatient","100.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BSS PLUS IO SOLN","81000092","CDM","0250","RC","Z7610","HCPCS","0065-0800-94","NDC","facility","inpatient","73.529411","ML",,"21.70","21.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BSS IO SOLN","81000092","CDM","0250","RC","0065-0795-15","NDC",,,"facility","inpatient","15.000000","ML","RISK","102.17","102.17",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"BSS IO SOLN","81000092","CDM","0250","RC","0065-0795-15","NDC",,,"facility","inpatient","16.464330","ML",,"92.42","92.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BSS IO SOLN","81000092","CDM","0250","RC","0065-0795-50","NDC",,,"facility","inpatient","500.000000","ML","RISK","289.25","289.25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"BSS IO SOLN","81000092","CDM","0250","RC","0065-0795-50","NDC",,,"facility","inpatient","552.892561","ML",,"261.13","261.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BSS PLUS IO SOLN","81000092","CDM","0250","RC","0065-0800-94","NDC",,,"facility","inpatient","500.000000","ML",,"737.75","737.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE (IO)","81000092","CDM","0250","RC","0264-1280-55","NDC",,,"facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","0264-2101-00","NDC",,,"facility","inpatient","1421.052631","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","0264-2201-10","NDC",,,"facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IR SOLN","81000092","CDM","0250","RC","0264-7389-60","NDC",,,"facility","inpatient","3164.383561","ML",,"72.27","72.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","0338-0003-44","NDC",,,"facility","inpatient","1099.173553","ML",,"71.85","71.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","0338-0003-47","NDC",,,"facility","inpatient","3000.000000","ML",,"67.22","67.22",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","0338-0004-04","NDC",,,"facility","inpatient","1251.392409","ML",,"74.06","74.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","0338-0047-27","NDC",,,"facility","inpatient","3292.148508","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","0338-0047-44","NDC",,,"facility","inpatient","1217.235045","ML",,"70.80","70.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","0338-0048-03","NDC",,,"facility","inpatient","523.663453","ML",,"72.21","72.21",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","0338-0048-04","NDC",,,"facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 3% IV CONTINUOUS INFUSION","81000092","CDM","0250","RC","0338-0054-03","NDC",,,"facility","inpatient","500.595060","ML",,"74.23","74.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE","81000092","CDM","0250","RC","0409-4902-34","NDC",,,"facility","inpatient","57.434944","ML",,"73.53","73.53",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","0409-6138-03","NDC",,,"facility","inpatient","500.000000","ML",,"68.76","68.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE","81000092","CDM","0250","RC","0409-6648-02","NDC",,,"facility","inpatient","50.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W COMPOUNDING - NON TPN IV SOLN SH","81000092","CDM","0250","RC","0409-6648-16","NDC",,,"facility","inpatient","50.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","0409-7138-09","NDC",,,"facility","inpatient","1031.578947","ML",,"72.03","72.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HETASTARCH-NACL 6-0.9 % IV SOLN","81000092","CDM","0250","RC","0409-7248-03","NDC",,,"facility","inpatient","500.000000","ML",,"149.5","149.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE","81000092","CDM","0250","RC","0409-7517-16","NDC",,,"facility","inpatient","85.294117","ML",,"69.65","69.65",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) 2 UNITS/ML 0.9% NACL LINE PATENCY DRIP (PREMIX) SH","81000092","CDM","0250","RC","0409-7620-03","NDC",,,"facility","inpatient","825.892857","ML",,"70.38","70.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HEPARIN (PORCINE) IN NACL 2000-0.9 UNIT/L-% IV SOLN","81000092","CDM","0250","RC","0409-7620-59","NDC",,,"facility","inpatient","1269.151138","ML",,"62.70","62.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORMOSOL-R PH 7.4 IV SOLN","81000092","CDM","0250","RC","0409-7670-03","NDC",,,"facility","inpatient","971.861471","ML",,"58.26","58.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORMOSOL-R PH 7.4 IV SOLN","81000092","CDM","0250","RC","0409-7670-09","NDC",,,"facility","inpatient","1000.000000","ML",,"55","55",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IR SOLN","81000092","CDM","0250","RC","0409-7828-08","NDC",,,"facility","inpatient","3000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORMOSOL-R IV SOLN","81000092","CDM","0250","RC","0409-7967-09","NDC",,,"facility","inpatient","3428.571428","ML",,"68.18","68.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","0409-7972-08","NDC",,,"facility","inpatient","3104.046242","ML",,"64.70","64.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","0409-7973-08","NDC",,,"facility","inpatient","3000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORMOSOL-R PH 7.4 IV SOLN","81000092","CDM","0250","RC","0990-7670-09","NDC",,,"facility","inpatient","1000.000000","ML",,"51.61","51.61",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D20W COMPOUNDING - NON TPN IV SOLN SH","81000092","CDM","0250","RC","0990-7935-19","NDC",,,"facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W COMPOUNDING - NON TPN IV SOLN SH","81000092","CDM","0250","RC","0990-7936-19","NDC",,,"facility","inpatient","1166.666666","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NORMOSOL-R IV SOLN","81000092","CDM","0250","RC","0990-7967-09","NDC",,,"facility","inpatient","2428.571428","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"STERILE WATER FOR IRRIGATION IR SOLN","81000092","CDM","0250","RC","50421-00877","NDC",,,"facility","inpatient","261.494252","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IR SOLN","81000092","CDM","0250","RC","57896-002-01","NDC",,,"facility","inpatient","100.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEL NIDO CARDIOPLEGIA WITH LIDOCAINE SOLN (PREMIX)","81000092","CDM","0250","RC","66647-0120-02","NDC",,,"facility","inpatient","1052.800000","ML",,"342.40","342.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE","81000092","CDM","0250","RC","76329-3302-1","NDC",,,"facility","inpatient","61.922723","ML",,"71.58","71.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"BELZER UW SOLN","81000092","CDM","0250","RC","81080-5000-04","NDC",,,"facility","inpatient","1000.000000","ML",,"1160","1160",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE","81000092","CDM","0250","RC","99999-0006-09","NDC",,,"facility","inpatient","60.256410","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GADOPENTETATE DIMEGLUMINE 469.01 MG/ML IV SOLN","81000094","CDM","0255","RC","A9579","HCPCS","50419-188-01","NDC","facility","inpatient","1.000000","ML",,"14.45","14.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0255","RC","A9585","HCPCS","50419-325-01","NDC","facility","inpatient","0.103596","ML","JZ","2.80","2.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0255","RC","A9585","HCPCS","50419-325-03","NDC","facility","inpatient","0.100000","ML","JZ","2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0255","RC","A9585","HCPCS","50419-325-11","NDC","facility","inpatient","0.100000","ML","JZ","2.81","2.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0255","RC","A9585","HCPCS","50419-325-12","NDC","facility","inpatient","0.106860","ML","JZ","2.80","2.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 10 MMOL/10ML IV SOSY","81000094","CDM","0255","RC","A9585","HCPCS","50419-325-28","NDC","facility","inpatient","0.100000","ML","JZ","2.99","2.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0255","RC","A9585","HCPCS","65219-281-08","NDC","facility","inpatient","0.100000","ML","JZ","1.95","1.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0255","RC","A9585","HCPCS","50419-325-12","NDC","facility","inpatient","0.100000","ML",,"2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0255","RC","A9585","HCPCS","50419-325-12","NDC","facility","inpatient","0.100000","ML","RISK","2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"PERFLUTREN PROTEIN A MICROSPH IV SUSP","81000094","CDM","0255","RC","Q9956","HCPCS","0407-2707-03","NDC","facility","inpatient","1.390096","ML",,"145.37","145.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP","81000094","CDM","0255","RC","Q9957","HCPCS","11994-011-01","NDC","facility","inpatient","1.153442","ML","JZ","408.07","408.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP","81000094","CDM","0255","RC","Q9957","HCPCS","11994-011-04","NDC","facility","inpatient","1.000000","ML","JZ","584.85","584.85",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP","81000094","CDM","0255","RC","Q9957","HCPCS","11994-011-04","NDC","facility","inpatient","4.750000","ML",,"438.64","438.64",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIATRIZOATE MEGLUMINE 30 % UR SOLN","81000094","CDM","0255","RC","Q9958","HCPCS","0270-0149-57","NDC","facility","inpatient","1.000000","ML",,"0.48","0.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIATRIZOATE MEGLUMINE 18 % UR SOLN","81000094","CDM","0255","RC","Q9958","HCPCS","0270-1410-30","NDC","facility","inpatient","3.666666","ML",,"0.36","0.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 180 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9965","HCPCS","0407-1411-10","NDC","facility","inpatient","1.376470","ML",,"13.45","13.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 180 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9965","HCPCS","0407-1411-20","NDC","facility","inpatient","1.160000","ML",,"8.76","8.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 180 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9965","HCPCS","0407-1411-20","NDC","facility","inpatient","1.000000","ML","XU","8.76","8.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"IOHEXOL 240 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9966","HCPCS","0407-1412-10","NDC","facility","inpatient","0.984375","ML","JZ","17.68","17.68",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 240 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9966","HCPCS","0407-1412-30","NDC","facility","inpatient","1.000000","ML","JZ","2.71","2.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-63","NDC","facility","inpatient","1.000000","ML","PN,JZ","3.05","3.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","65219-383-08","NDC","facility","inpatient","0.999819","ML",,"2.78","2.78",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","65219-383-04","NDC","facility","inpatient","5.000000","ML",,"3.05","3.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-2223-23","NDC","facility","inpatient","1.000000","ML",,"3.11","3.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1414-98","NDC","facility","inpatient","1.167485","ML",,"3.36","3.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1414-93","NDC","facility","inpatient","1.000000","ML",,"3.12","3.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1414-72","NDC","facility","inpatient","1.108521","ML",,"2.83","2.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-72","NDC","facility","inpatient","1.120548","ML",,"2.81","2.81",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-42","NDC","facility","inpatient","1.149159","ML","JZ","3.62","3.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-50","NDC","facility","inpatient","1.000000","ML","JZ","3.02","3.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-59","NDC","facility","inpatient","1.217391","ML","JZ","4.36","4.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-61","NDC","facility","inpatient","1.143523","ML","JZ","3.44","3.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-63","NDC","facility","inpatient","1.153720","ML","JZ","2.99","2.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-65","NDC","facility","inpatient","1.372111","ML","JZ","2.87","2.87",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-86","NDC","facility","inpatient","1.000000","ML","JZ","3.51","3.51",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1414-03","NDC","facility","inpatient","1.000000","ML","JZ","3.02","3.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1414-89","NDC","facility","inpatient","1.242378","ML","JZ","3.40","3.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1414-90","NDC","facility","inpatient","1.068785","ML","JZ","3.37","3.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1414-91","NDC","facility","inpatient","1.121437","ML","JZ","3.38","3.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1414-93","NDC","facility","inpatient","1.100413","ML","JZ","3.12","3.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-2223-01","NDC","facility","inpatient","1.000000","ML","JZ","5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-2223-02","NDC","facility","inpatient","1.316850","ML","JZ","3.72","3.72",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-2223-16","NDC","facility","inpatient","1.249843","ML","JZ","3.60","3.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-2223-17","NDC","facility","inpatient","1.482758","ML","JZ","3.56","3.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-2223-19","NDC","facility","inpatient","1.204699","ML","JZ","3.34","3.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-2223-21","NDC","facility","inpatient","1.266308","ML","JZ","3.03","3.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0407-1413-10","NDC","facility","inpatient","3.580645","ML","JZ","3.15","3.15",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOPAMIDOL 76 % IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0270-1316-35","NDC","facility","inpatient","2.713450","ML","JZ","1.73","1.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOPAMIDOL 61 % IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0270-1315-25","NDC","facility","inpatient","1.000000","ML","JZ","3.27","3.27",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOPAMIDOL 61 % IV SOLN","81000094","CDM","0255","RC","Q9967","HCPCS","0270-1315-30","NDC","facility","inpatient","1.000000","ML","JZ","1.57","1.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOPENTETATE DIMEGLUMINE 469.01 MG/ML IV SOLN","81000094","CDM","0636","RC","A9579","HCPCS","50419-188-01","NDC","facility","outpatient","1.000000","ML",,"14.45","14.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GADOBUTROL 10 MMOL/10ML IV SOSY","81000094","CDM","0636","RC","A9585","HCPCS","50419-325-28","NDC","facility","outpatient","0.100000","ML","JZ","2.99","2.99",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0636","RC","A9585","HCPCS","50419-325-01","NDC","facility","outpatient","0.102364","ML","JZ","2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0636","RC","A9585","HCPCS","50419-325-03","NDC","facility","outpatient","0.100000","ML","JZ","2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0636","RC","A9585","HCPCS","50419-325-11","NDC","facility","outpatient","0.124054","ML","JZ","2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0636","RC","A9585","HCPCS","50419-325-12","NDC","facility","outpatient","0.106540","ML","JZ","2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0636","RC","A9585","HCPCS","65219-281-08","NDC","facility","outpatient","0.100000","ML","JZ","1.95","1.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0636","RC","A9585","HCPCS","50419-325-12","NDC","facility","outpatient","0.100000","ML",,"2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0636","RC","A9585","HCPCS","50419-325-11","NDC","facility","outpatient","0.100000","ML",,"2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"GADOBUTROL 1 MMOL/ML IV SOLN","81000094","CDM","0636","RC","A9585","HCPCS","50419-325-01","NDC","facility","outpatient","0.100000","ML","RISK","2.79","2.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"PERFLUTREN PROTEIN A MICROSPH IV SUSP","81000094","CDM","0636","RC","Q9956","HCPCS","0407-2707-03","NDC","facility","outpatient","1.858333","ML",,"137.59","137.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP","81000094","CDM","0636","RC","Q9957","HCPCS","11994-011-01","NDC","facility","outpatient","0.690801","ML","JZ","344.11","344.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP","81000094","CDM","0636","RC","Q9957","HCPCS","11994-011-04","NDC","facility","outpatient","0.442500","ML","JZ","268.36","268.36",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"DIATRIZOATE MEGLUMINE 30 % UR SOLN","81000094","CDM","0636","RC","Q9958","HCPCS","0270-0149-57","NDC","facility","outpatient","1.727272","ML",,"0.62","0.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DIATRIZOATE MEGLUMINE 18 % UR SOLN","81000094","CDM","0636","RC","Q9958","HCPCS","0270-1410-30","NDC","facility","outpatient","1.000000","ML",,"0.38","0.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 180 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9965","HCPCS","0407-1411-10","NDC","facility","outpatient","1.000000","ML","59","13.45","13.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier 59: Distinct Procedural Service"
"IOHEXOL 180 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9965","HCPCS","0407-1411-10","NDC","facility","outpatient","1.000000","ML",,"13.45","13.45",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 180 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9965","HCPCS","0407-1411-20","NDC","facility","outpatient","1.000000","ML",,"8.76","8.76",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 240 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9966","HCPCS","0407-1412-10","NDC","facility","outpatient","0.996732","ML","JZ","15.00","15.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 240 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9966","HCPCS","0407-1412-30","NDC","facility","outpatient","1.000000","ML","JZ","2.75","2.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-50","NDC","facility","outpatient","1.000000","ML","JZ","3.02","3.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1414-91","NDC","facility","outpatient","1.036671","ML","JZ","3.39","3.39",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1414-90","NDC","facility","outpatient","1.011809","ML","JZ","3.38","3.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1414-89","NDC","facility","outpatient","1.126924","ML","JZ","3.47","3.47",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-86","NDC","facility","outpatient","2.233806","ML","JZ","3.62","3.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-65","NDC","facility","outpatient","1.201442","ML","JZ","2.97","2.97",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-63","NDC","facility","outpatient","1.076302","ML","JZ","3.05","3.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-62","NDC","facility","outpatient","1.000000","ML","JZ","3.11","3.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-61","NDC","facility","outpatient","1.011117","ML","JZ","3.23","3.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1414-93","NDC","facility","outpatient","1.127025","ML","JZ","3.13","3.13",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-2223-02","NDC","facility","outpatient","1.708965","ML","JZ","3.74","3.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-2223-16","NDC","facility","outpatient","1.138860","ML","JZ","3.59","3.59",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-2223-17","NDC","facility","outpatient","1.000000","ML","JZ","3.56","3.56",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-63","NDC","facility","outpatient","1.000000","ML","PN,JZ","3.05","3.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","65219-383-08","NDC","facility","outpatient","1.571428","ML",,"3.24","3.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","65219-383-04","NDC","facility","outpatient","1.061162","ML",,"3.11","3.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-59","NDC","facility","outpatient","1.113031","ML","JZ","4.66","4.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-2223-23","NDC","facility","outpatient","1.000000","ML",,"3.11","3.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1414-98","NDC","facility","outpatient","1.560716","ML",,"3.07","3.07",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 350 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1414-72","NDC","facility","outpatient","1.090896","ML",,"2.88","2.88",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-72","NDC","facility","outpatient","1.089835","ML",,"2.84","2.84",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-63","NDC","facility","outpatient","1.000000","ML",,"3.05","3.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-59","NDC","facility","outpatient","1.000000","ML",,"4.66","4.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-86","NDC","facility","outpatient","1.000000","ML","JZ,XU","3.42","3.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-2223-21","NDC","facility","outpatient","1.848314","ML","JZ","3.03","3.03",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IODIXANOL 320 MG/ML IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-2223-19","NDC","facility","outpatient","1.320872","ML","JZ","3.34","3.34",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-42","NDC","facility","outpatient","12.760000","ML",,"3.79","3.79",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"IOPAMIDOL 61 % IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0270-1315-25","NDC","facility","outpatient","1.000000","ML","JZ","6.52","6.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOPAMIDOL 61 % IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0270-1315-30","NDC","facility","outpatient","1.000000","ML","JZ","1.57","1.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOPAMIDOL 76 % IV SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0270-1316-35","NDC","facility","outpatient","3.173076","ML","JZ","5","5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-10","NDC","facility","outpatient","1.107816","ML","JZ","13.83","13.83",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"IOHEXOL 300 MG/ML IJ SOLN","81000094","CDM","0636","RC","Q9967","HCPCS","0407-1413-42","NDC","facility","outpatient","1.048740","ML","JZ","3.70","3.70",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient"
"NACL 0.9% IV SOLN","82000000","CDM","0258","RC","J7030","HCPCS","17271-701-07","NDC","facility","inpatient","4500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IJ SOLN RADIOLOGY SH","82000000","CDM","0258","RC","J7030","HCPCS","0338-0049-04","NDC","facility","inpatient","1045.670586","ML",,"73.31","73.31",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000000","CDM","0258","RC","J7030","HCPCS","0338-0049-03","NDC","facility","inpatient","1200.176710","ML",,"41.67","41.67",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% BOLUS IV SOLN CUSTOM CREATE","82000000","CDM","0258","RC","J7030","HCPCS","0264-7800-00","NDC","facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% BOLUS IV SOLN CUSTOM CREATE","82000000","CDM","0258","RC","J7030","HCPCS","0409-7983-09","NDC","facility","inpatient","1153.433121","ML",,"64.16","64.16",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000000","CDM","0258","RC","J7040","HCPCS","0338-0049-03","NDC","facility","inpatient","551.361655","ML",,"74.06","74.06",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0258","RC","J7040","HCPCS","17271-701-06","NDC","facility","inpatient","530.232558","ML",,"71.10","71.10",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0258","RC","J7042","HCPCS","0264-7610-00","NDC","facility","inpatient","500.000000","ML",,"33.50","33.50",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.9% IV SOLN","82000000","CDM","0258","RC","J7042","HCPCS","0338-0089-03","NDC","facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0258","RC","J7042","HCPCS","0338-0089-04","NDC","facility","inpatient","546.920821","ML",,"37.60","37.60",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0258","RC","J7050","HCPCS","0990-7983-03","NDC","facility","inpatient","330.645161","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000000","CDM","0258","RC","J7050","HCPCS","0338-0049-02","NDC","facility","inpatient","223.888888","ML",,"10.95","10.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0258","RC","J7050","HCPCS","0990-7983-02","NDC","facility","inpatient","750.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0258","RC","J7050","HCPCS","17271-701-05","NDC","facility","inpatient","324.683593","ML",,"73.09","73.09",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0258","RC","J7050","HCPCS","63323-623-74","NDC","facility","inpatient","1750.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0258","RC","J7050","HCPCS","65219-472-05","NDC","facility","inpatient","305.555555","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0258","RC","J7060","HCPCS","63323-624-04","NDC","facility","inpatient","238.208333","ML",,"73.44","73.44",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0258","RC","J7060","HCPCS","0990-7922-61","NDC","facility","inpatient","156.194589","ML",,"73.52","73.52",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0258","RC","J7060","HCPCS","0990-7922-03","NDC","facility","inpatient","538.461538","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0258","RC","J7060","HCPCS","0338-0017-03","NDC","facility","inpatient","551.504297","ML",,"74.24","74.24",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0258","RC","J7060","HCPCS","0990-7922-09","NDC","facility","inpatient","500.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0258","RC","J7070","HCPCS","0338-0017-04","NDC","facility","inpatient","1051.827823","ML",,"73.11","73.11",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0258","RC","J7070","HCPCS","0409-7922-09","NDC","facility","inpatient","1114.285714","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0258","RC","J7120","HCPCS","0264-7750-00","NDC","facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0258","RC","J7120","HCPCS","0264-7750-10","NDC","facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0258","RC","J7120","HCPCS","0338-0117-03","NDC","facility","inpatient","657.614035","ML",,"73.58","73.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0258","RC","J7120","HCPCS","0338-0117-04","NDC","facility","inpatient","1092.041996","ML",,"73.35","73.35",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0258","RC","J7120","HCPCS","0409-7953-03","NDC","facility","inpatient","380.004412","ML",,"73.30","73.30",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0258","RC","J7120","HCPCS","0409-7953-48","NDC","facility","inpatient","1000.000000","ML",,"114.43","114.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0258","RC","J7120","HCPCS","0990-7953-03","NDC","facility","inpatient","900.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0258","RC","J7120","HCPCS","0338-0117-04","NDC","facility","inpatient","1000.000000","ML","RISK","37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier RI: Ramus intermedius coronary artery | Modifier SK: Member of high risk population (use only with codes for immunization)"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0258","RC","J7799","HCPCS","0264-7610-00","NDC","facility","inpatient","500.000000","ML",,"33.89","33.89",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN","82000000","CDM","0258","RC","J7799","HCPCS","0338-0085-03","NDC","facility","inpatient","500.000000","ML",,"64.29","64.29",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% IV SOLN","82000000","CDM","0258","RC","J7799","HCPCS","0338-0085-04","NDC","facility","inpatient","526.132994","ML",,"36.95","36.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0258","RC","J7799","HCPCS","0338-0089-04","NDC","facility","inpatient","614.179104","ML",,"36.08","36.08",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN","82000000","CDM","0258","RC","J7799","HCPCS","0409-7926-03","NDC","facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% IV SOLN","82000000","CDM","0258","RC","J7799","HCPCS","0409-7926-09","NDC","facility","inpatient","595.238095","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN","82000000","CDM","0258","RC","J7799","HCPCS","0264-7612-00","NDC","facility","inpatient","633.333333","ML",,"34.62","34.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IJ SOLN RADIOLOGY SH","82000000","CDM","0636","RC","J7030","HCPCS","0338-0049-04","NDC","facility","outpatient","1160.063374","ML",,"68.37","68.37",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% BOLUS IV SOLN CUSTOM CREATE","82000000","CDM","0636","RC","J7030","HCPCS","0264-7800-00","NDC","facility","outpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000000","CDM","0636","RC","J7030","HCPCS","0338-0049-03","NDC","facility","outpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% BOLUS IV SOLN CUSTOM CREATE","82000000","CDM","0636","RC","J7030","HCPCS","0409-7983-09","NDC","facility","outpatient","1214.401129","ML",,"67.66","67.66",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IJ SOLN RADIOLOGY SH","82000000","CDM","0636","RC","J7030","HCPCS","0338-0049-04","NDC","facility","outpatient","1074.301369","ML","PN","73","73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000000","CDM","0636","RC","J7040","HCPCS","0338-0049-03","NDC","facility","outpatient","553.864768","ML",,"70.18","70.18",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7040","HCPCS","17271-701-06","NDC","facility","outpatient","3700.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7040","HCPCS","0264-7800-10","NDC","facility","outpatient","513.245033","ML","PN","73.02","73.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000000","CDM","0636","RC","J7040","HCPCS","0338-0049-03","NDC","facility","outpatient","476.744488","ML","PN","65.96","65.96",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7040","HCPCS","76297-001-02","NDC","facility","outpatient","518.691588","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0636","RC","J7042","HCPCS","0338-0089-04","NDC","facility","outpatient","673.228346","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7042","HCPCS","0409-7941-09","NDC","facility","outpatient","500.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0636","RC","J7042","HCPCS","0264-7610-00","NDC","facility","outpatient","6500.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000000","CDM","0636","RC","J7050","HCPCS","0338-0049-02","NDC","facility","outpatient","243.187500","ML",,"11.91","11.91",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7050","HCPCS","17271-701-05","NDC","facility","outpatient","273.437500","ML","PN","63.92","63.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000000","CDM","0636","RC","J7050","HCPCS","0338-0049-02","NDC","facility","outpatient","475.806451","ML","PN","12.3","12.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7050","HCPCS","17271-701-05","NDC","facility","outpatient","194.186046","ML",,"65.92","65.92",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7050","HCPCS","0990-7983-61","NDC","facility","outpatient","150.000000","ML",,"11.4","11.4",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7050","HCPCS","0990-7983-02","NDC","facility","outpatient","250.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN","82000000","CDM","0636","RC","J7050","HCPCS","76297-001-31","NDC","facility","outpatient","296.955719","ML","PN","72.75","72.75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"D5W IV SOLN","82000000","CDM","0636","RC","J7060","HCPCS","0990-7922-02","NDC","facility","outpatient","248.933333","ML","PN","75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"D5W IV SOLN","82000000","CDM","0636","RC","J7060","HCPCS","0338-0017-03","NDC","facility","outpatient","372.044506","ML","PN","73.77","73.77",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"D5W IV SOLN","82000000","CDM","0636","RC","J7060","HCPCS","0338-0017-02","NDC","facility","outpatient","583.333333","ML","PN","12.3","12.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"D5W IV SOLN","82000000","CDM","0636","RC","J7060","HCPCS","0338-0017-48","NDC","facility","outpatient","100.000000","ML",,"10.95","10.95",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0636","RC","J7060","HCPCS","0990-7922-61","NDC","facility","outpatient","200.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0636","RC","J7060","HCPCS","0338-0017-03","NDC","facility","outpatient","557.971014","ML",,"62","62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0636","RC","J7060","HCPCS","0338-0017-02","NDC","facility","outpatient","2250.000000","ML",,"12.3","12.3",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0636","RC","J7060","HCPCS","0338-0017-41","NDC","facility","outpatient","50.000000","ML",,"10.5","10.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0636","RC","J7070","HCPCS","0338-0017-04","NDC","facility","outpatient","1270.967741","ML",,"69.26","69.26",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W IV SOLN","82000000","CDM","0636","RC","J7070","HCPCS","0409-7922-09","NDC","facility","outpatient","1888.888888","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0636","RC","J7120","HCPCS","0264-7750-00","NDC","facility","outpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0636","RC","J7120","HCPCS","0338-0117-03","NDC","facility","outpatient","840.905660","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0636","RC","J7120","HCPCS","0338-0117-04","NDC","facility","outpatient","1754.249410","ML",,"63.80","63.80",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0636","RC","J7120","HCPCS","0409-7953-48","NDC","facility","outpatient","1000.000000","ML",,"114.43","114.43",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"LACTATED RINGERS IV SOLN","82000000","CDM","0636","RC","J7120","HCPCS","0409-7953-03","NDC","facility","outpatient","391.662538","ML",,"70.38","70.38",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0636","RC","J7799","HCPCS","0264-7610-00","NDC","facility","outpatient","1166.666666","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN","82000000","CDM","0636","RC","J7799","HCPCS","0338-0085-03","NDC","facility","outpatient","1500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% IV SOLN","82000000","CDM","0636","RC","J7799","HCPCS","0338-0085-04","NDC","facility","outpatient","703.676470","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0636","RC","J7799","HCPCS","0338-0089-04","NDC","facility","outpatient","820.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% IV SOLN","82000000","CDM","0636","RC","J7799","HCPCS","0409-7926-09","NDC","facility","outpatient","833.333333","ML",,"6.02","6.02",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN","82000000","CDM","0636","RC","J7799","HCPCS","0409-7941-03","NDC","facility","outpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PLASMA-LYTE A IV SOLN","82000001","CDM","0258","RC","J3490","HCPCS","0338-0221-04","NDC","facility","inpatient","1940.157480","ML",,"116.42","116.42",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IJ SOLN RADIOLOGY SH","82000001","CDM","0258","RC","J7030","HCPCS","0338-0049-04","NDC","facility","inpatient","674.388157","ML",,"72.90","72.90",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000001","CDM","0258","RC","J7040","HCPCS","0338-0049-03","NDC","facility","inpatient","173.103255","ML",,"68.63","68.63",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% IV SOLN FOR LINE FLUSH OR PRIME TKO","82000001","CDM","0258","RC","J7050","HCPCS","0338-0049-02","NDC","facility","inpatient","212.000000","ML",,"11.73","11.73",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D10W - NACL 0.45% IV SOLN","82000001","CDM","0258","RC","J7799","HCPCS","0264-7622-00","NDC","facility","inpatient","500.000000","ML",,"37.5","37.5",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D10W - NACL 0.45% IV SOLN","82000001","CDM","0258","RC","X7700","HCPCS","0264-7622-00","NDC","facility","inpatient","1666.666666","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D20W COMPOUNDING - NON TPN IV SOLN SH","82000001","CDM","0258","RC","X7700","HCPCS","0990-7935-19","NDC","facility","inpatient","1500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D10W IV SOLN","82000001","CDM","0258","RC","0264-7520-10","NDC",,,"facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D10W - NACL 0.45% IV SOLN","82000001","CDM","0258","RC","0264-7622-00","NDC",,,"facility","inpatient","1842.105263","ML",,"72.32","72.32",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D10W NEO IV SOLN","82000001","CDM","0258","RC","0338-0023-03","NDC",,,"facility","inpatient","659.010600","ML",,"73.74","73.74",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D10W IV SOLN","82000001","CDM","0258","RC","0338-0023-04","NDC",,,"facility","inpatient","1089.527872","ML",,"73.58","73.58",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.45% IV SOLN","82000001","CDM","0258","RC","0338-0043-03","NDC",,,"facility","inpatient","547.960585","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.45% IV SOLN","82000001","CDM","0258","RC","0338-0043-04","NDC",,,"facility","inpatient","1102.552006","ML",,"74.86","74.86",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 3% IV CONTINUOUS INFUSION","82000001","CDM","0258","RC","0338-0054-03","NDC",,,"facility","inpatient","556.767496","ML",,"74.48","74.48",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - NACL 0.45% IV SOLN","82000001","CDM","0258","RC","0338-0085-04","NDC",,,"facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"PLASMA-LYTE A IV SOLN","82000001","CDM","0258","RC","0338-0221-04","NDC",,,"facility","inpatient","1975.403012","ML",,"113.93","113.93",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D70W IV SOLN","82000001","CDM","0258","RC","0338-0719-06","NDC",,,"facility","inpatient","1999.644929","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE","82000001","CDM","0258","RC","0409-4902-34","NDC",,,"facility","inpatient","57.792207","ML",,"65.62","65.62",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE","82000001","CDM","0258","RC","0409-6648-02","NDC",,,"facility","inpatient","50.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W COMPOUNDING - NON TPN IV SOLN SH","82000001","CDM","0258","RC","0409-6648-16","NDC",,,"facility","inpatient","50.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D10W IV SOLN","82000001","CDM","0258","RC","0409-7930-03","NDC",,,"facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.45% IV SOLN","82000001","CDM","0258","RC","0409-7985-03","NDC",,,"facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.45% IV SOLN","82000001","CDM","0258","RC","0409-7985-09","NDC",,,"facility","inpatient","2333.333333","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D70W IV SOLN","82000001","CDM","0258","RC","0990-7120-07","NDC",,,"facility","inpatient","2390.019511","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D70W IV SOLN","82000001","CDM","0258","RC","0990-7918-19","NDC",,,"facility","inpatient","674.784555","ML",,"73.71","73.71",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D20W COMPOUNDING - NON TPN IV SOLN SH","82000001","CDM","0258","RC","0990-7935-19","NDC",,,"facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W COMPOUNDING - NON TPN IV SOLN SH","82000001","CDM","0258","RC","0990-7936-19","NDC",,,"facility","inpatient","572.002388","ML",,"73.40","73.40",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.45% IV SOLN","82000001","CDM","0258","RC","0990-7985-09","NDC",,,"facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 4 MEQ/ML ORAL SOLUTION","82000001","CDM","0258","RC","63323-093-01","NDC",,,"facility","inpatient","30.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 23.4 % IV SOLN (HYPERTONIC) SH","82000001","CDM","0258","RC","63323-095-61","NDC",,,"facility","inpatient","100.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"SODIUM CHLORIDE 4 MEQ/ML ORAL SOLUTION","82000001","CDM","0258","RC","63323-187-30","NDC",,,"facility","inpatient","30.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL NEO/PED BOLUS SOLN CUSTOM CREATE","82000001","CDM","0258","RC","63807-100-11","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL NEO/PED BOLUS SOLN CUSTOM CREATE","82000001","CDM","0258","RC","63807-100-91","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D50W IV SOLN PRELOAD SYRINGE","82000001","CDM","0258","RC","76329-3302-1","NDC",,,"facility","inpatient","75.000000","ML",,"25","25",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"NACL 0.9% FLUSH IV SOLN CONSOLIDATED","82000001","CDM","0258","RC","8290-306499","NDC",,,"facility","inpatient","10.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0258","RC","J7121","HCPCS","0409-7929-09","NDC","facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0258","RC","J7121","HCPCS","0264-7751-10","NDC","facility","inpatient","595.238095","ML",,"69.23","69.23",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0258","RC","J7121","HCPCS","0338-0125-04","NDC","facility","inpatient","1413.050314","ML",,"74.12","74.12",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0258","RC","J7121","HCPCS","0338-0125-03","NDC","facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0258","RC","J7121","HCPCS","0409-7929-03","NDC","facility","inpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0258","RC","0264-7751-00","NDC",,,"facility","inpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0258","RC","0338-0125-04","NDC",,,"facility","inpatient","1533.648677","ML",,"72.57","72.57",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0636","RC","J7121","HCPCS","0338-0125-04","NDC","facility","outpatient","1405.660377","ML",,"72.00","72.00",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0636","RC","J7121","HCPCS","0264-7751-10","NDC","facility","outpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0636","RC","J7121","HCPCS","0264-7751-00","NDC","facility","outpatient","1000.000000","ML",,"11.05","11.05",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0636","RC","J7121","HCPCS","0409-7929-09","NDC","facility","outpatient","1000.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"D5W - LACTATED RINGERS IV SOLN","82000002","CDM","0636","RC","J7121","HCPCS","0409-7929-03","NDC","facility","outpatient","500.000000","ML",,"75","75",,,,,,,,,,,,,"Gross Charge Type: Pharmacy"
"HCHG VAC COVID-19 ASTRZNC SARSCOV2 5X1010VP/.5MLIM","83200003","CDM","636","RC","91302","HCPCS",,,"facility","inpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VAC COVID-19 ASTRZNC SARSCOV2 5X1010VP/.5MLIM","83200003","CDM","636","RC","91302","HCPCS",,,"facility","outpatient",,,,"0.01","0.01",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RHC IMM ADMN SARSCOV2 VACCINE 1ST/ONLY COMPNT","87000382","CDM","90480","HCPCS",,,,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RHC IMM ADMN SARSCOV2 VACCINE 1ST/ONLY COMPNT","87000382","CDM","90480","HCPCS",,,,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC EXAM NEW PT INTERMEDIATE","87200007","CDM","510","RC","92002","HCPCS",,,"facility","inpatient",,,,"294","294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC EXAM NEW PT INTERMEDIATE","87200007","CDM","510","RC","92002","HCPCS",,,"facility","outpatient",,,,"294","294",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC EXAM NEW PT COMPREHENSIVE","87200008","CDM","510","RC","92004","HCPCS",,,"facility","inpatient",,,,"341","341",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC EXAM NEW PT COMPREHENSIVE","87200008","CDM","510","RC","92004","HCPCS",,,"facility","outpatient",,,,"339","339",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC EXAM EST PT INTERMEDIATE","87200009","CDM","510","RC","92012","HCPCS",,,"facility","inpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC EXAM EST PT INTERMEDIATE","87200009","CDM","510","RC","92012","HCPCS",,,"facility","outpatient",,,,"296","296",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC EXAM EST PT COMPREHENSIVE","87200010","CDM","510","RC","92014","HCPCS",,,"facility","inpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC EXAM EST PT COMPREHENSIVE","87200010","CDM","510","RC","92014","HCPCS",,,"facility","outpatient",,,,"286","286",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VISUAL FIELD EXAM WITH INTERPRETATION AND REPORT,","87200012","CDM","510","RC","92081","HCPCS",,,"facility","inpatient",,,,"615","615",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VISUAL FIELD EXAM WITH INTERPRETATION AND REPORT,","87200012","CDM","510","RC","92081","HCPCS",,,"facility","outpatient",,,,"615","615",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDOCYANINE GREEN ANGIOGRAPHY BI","87200017","CDM","510","RC","92240","HCPCS",,,"facility","inpatient",,,,"985","985",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDOCYANINE GREEN ANGIOGRAPHY BI","87200017","CDM","510","RC","92240","HCPCS",,,"facility","outpatient",,,,"985","985",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FUNDUS PHOTOGRAPHY","87200018","CDM","510","RC","92250","HCPCS",,,"facility","inpatient",,,,"592","592",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FUNDUS PHOTOGRAPHY","87200018","CDM","510","RC","92250","HCPCS",,,"facility","outpatient",,,,"592","592",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCULOGRAPHY ELECTIVE","87200019","CDM","510","RC","92270","HCPCS",,,"facility","inpatient",,,,"1179","1179",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OCULOGRAPHY ELECTIVE","87200019","CDM","510","RC","92270","HCPCS",,,"facility","outpatient",,,,"1179","1179",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLOR VISION EXAM EXTENDED","87200021","CDM","510","RC","92283","HCPCS",,,"facility","inpatient",,,,"407","407",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLOR VISION EXAM EXTENDED","87200021","CDM","510","RC","92283","HCPCS",,,"facility","outpatient",,,,"407","407",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SLIT LAMP PROCEDURE","87200023","CDM","510","RC","92285","HCPCS",,,"facility","inpatient",,,,"622","622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SLIT LAMP PROCEDURE","87200023","CDM","510","RC","92285","HCPCS",,,"facility","outpatient",,,,"622","622",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANT SGM IMAGING W/MICROSCOPY ENDOTHELIAL ANALY","87200024","CDM","510","RC","92286","HCPCS",,,"facility","inpatient",,,,"537","537",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANT SGM IMAGING W/MICROSCOPY ENDOTHELIAL ANALY","87200024","CDM","510","RC","92286","HCPCS",,,"facility","outpatient",,,,"537","537",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOPOGRAPHY CORNEAL","87200026","CDM","510","RC","92025","HCPCS",,,"facility","inpatient",,,,"394","394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TOPOGRAPHY CORNEAL","87200026","CDM","510","RC","92025","HCPCS",,,"facility","outpatient",,,,"394","394",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MEDICAL NUTRITION THERAPY ASSESSMENT AND INTERVENT","87200035","CDM","942","RC","97802","HCPCS",,,"facility","inpatient",,,,"149","149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MEDICAL NUTRITION THERAPY ASSESSMENT AND INTERVENT","87200035","CDM","942","RC","97802","HCPCS",,,"facility","outpatient",,,,"149","149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MEDICAL NUTRITION THERAPY REASSESSMENT AND INTERVE","87200036","CDM","942","RC","97803","HCPCS",,,"facility","inpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MEDICAL NUTRITION THERAPY REASSESSMENT AND INTERVE","87200036","CDM","942","RC","97803","HCPCS",,,"facility","outpatient",,,,"145","145",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 1","87200049","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"278","278",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 1","87200049","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"278","278",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UC CLINIC LEVEL 1","87200050","CDM","516","RC","G0463","HCPCS",,,"facility","inpatient",,,,"278","278",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UC CLINIC LEVEL 1","87200050","CDM","516","RC","G0463","HCPCS",,,"facility","outpatient",,,,"278","278",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 2","87200051","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"355","355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 2","87200051","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"355","355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UC CLINIC LEVEL 2","87200052","CDM","516","RC","G0463","HCPCS",,,"facility","inpatient",,,,"355","355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UC CLINIC LEVEL 2","87200052","CDM","516","RC","G0463","HCPCS",,,"facility","outpatient",,,,"355","355",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 3","87200053","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"409","409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 3","87200053","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"409","409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 4","87200055","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"470","470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 4","87200055","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"470","470",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 5","87200057","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"540","540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 5","87200057","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"540","540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIABETES SELF MANAGEMENT TRAINING INDIVIDUAL EA 30 MIN","87200071","CDM","942","RC","G0108","HCPCS",,,"facility","inpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIABETES SELF MANAGEMENT TRAINING INDIVIDUAL EA 30 MIN","87200071","CDM","942","RC","G0108","HCPCS",,,"facility","outpatient",,,,"219","219",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INITIAL IMMUNIZATION ADMINISTRATION","87200073","CDM","771","RC","90471","HCPCS",,,"facility","inpatient",,,,"204","204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INITIAL IMMUNIZATION ADMINISTRATION","87200073","CDM","771","RC","90471","HCPCS",,,"facility","outpatient",,,,"204","204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EACH ADDITIONAL IMMUNIZATION ADMINISTRATION","87200074","CDM","771","RC","90472","HCPCS",,,"facility","inpatient",,,,"150","150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EACH ADDITIONAL IMMUNIZATION ADMINISTRATION","87200074","CDM","771","RC","90472","HCPCS",,,"facility","outpatient",,,,"150","150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONTINUOUS GLUCOSE MONITORING UP TO 72 HR","87200076","CDM","920","RC","95250","HCPCS",,,"facility","inpatient",,,,"940","940",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONTINUOUS GLUCOSE MONITORING UP TO 72 HR","87200076","CDM","920","RC","95250","HCPCS",,,"facility","outpatient",,,,"940","940",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELF MANAGEMENT EDUCATION 1 PATIENT 30 MIN","87200078","CDM","942","RC","98960","HCPCS",,,"facility","inpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SELF MANAGEMENT EDUCATION 1 PATIENT 30 MIN","87200078","CDM","942","RC","98960","HCPCS",,,"facility","outpatient",,,,"220","220",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA VACCINE ADMINSTRATION","87200081","CDM","771","RC","G0008","HCPCS",,,"facility","inpatient",,,,"193","193",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFLUENZA VACCINE ADMINSTRATION","87200081","CDM","771","RC","G0008","HCPCS",,,"facility","outpatient",,,,"193","193",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PNEUMOCOCCAL VACCINE ADMINISTRATION","87200082","CDM","771","RC","G0009","HCPCS",,,"facility","inpatient",,,,"181","181",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PNEUMOCOCCAL VACCINE ADMINISTRATION","87200082","CDM","771","RC","G0009","HCPCS",,,"facility","outpatient",,,,"181","181",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS VACCINE ADMINISTRATION","87200083","CDM","771","RC","G0010","HCPCS",,,"facility","inpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS VACCINE ADMINISTRATION","87200083","CDM","771","RC","G0010","HCPCS",,,"facility","outpatient",,,,"147","147",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIABETES SELF MANAGEMENT TRAINING GROUP EA 30 MIN","87200084","CDM","942","RC","G0109","HCPCS",,,"facility","inpatient",,,,"96","96",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIABETES SELF MANAGEMENT TRAINING GROUP EA 30 MIN","87200084","CDM","942","RC","G0109","HCPCS",,,"facility","outpatient",,,,"96","96",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS CENTER COORDINATOR REPORT","87200094","CDM",,,,,,,"facility","inpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS CENTER COORDINATOR REPORT","87200094","CDM",,,,,,,"facility","outpatient",,,,"176","176",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS ASSESS RN SPECIAL 30M","87200096","CDM",,,,,,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS ASSESS RN SPECIAL 30M","87200096","CDM",,,,,,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS RPT CMPLX/PERIOCID RN","87200097","CDM",,,,,,,"facility","inpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS RPT CMPLX/PERIOCID RN","87200097","CDM",,,,,,,"facility","outpatient",,,,"94","94",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS EVAL INTERVENTION SW 30M","87200100","CDM",,,,,,,"facility","inpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS EVAL INTERVENTION SW 30M","87200100","CDM",,,,,,,"facility","outpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS MEDICAL CASE CONF RN 15M","87200102","CDM",,,,,,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS MEDICAL CASE CONF RN 15M","87200102","CDM",,,,,,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS MEDICAL CASE CONF SW 15M","87200103","CDM",,,,,,,"facility","inpatient",,,,"41","41",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS MEDICAL CASE CONF SW 15M","87200103","CDM",,,,,,,"facility","outpatient",,,,"41","41",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS ALLIED HLTH  TELE CONSULT EA 15 MI","87200107","CDM",,,,,,,"facility","inpatient",,,,"57","57",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS ALLIED HLTH  TELE CONSULT EA 15 MI","87200107","CDM",,,,,,,"facility","outpatient",,,,"57","57",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ TENDON SHEATH OR LIGAMENT SINGLE BILAT","87200137","CDM","510","RC","20550","HCPCS",,,"facility","outpatient",,,"50","2400","2400",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG SCREEN PURE TONE AIR","87200142","CDM","471","RC","92551","HCPCS",,,"facility","inpatient",,,"GY","63","63",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG SCREEN PURE TONE AIR","87200142","CDM","471","RC","92551","HCPCS",,,"facility","outpatient",,,"GY","63","63",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG HEPATITIS B VACCINE ADMIN","87200169","CDM","771","RC","90471","HCPCS",,,"facility","inpatient",,,,"204","204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HEPATITIS B VACCINE ADMIN","87200169","CDM","771","RC","90471","HCPCS",,,"facility","outpatient",,,,"204","204",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNE ADMINISTRATION <=18 W/CS 1ST CP","87200173","CDM",,,,,,,"facility","inpatient",,,,"337","337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMMUNE ADMINISTRATION <=18 W/CS 1ST CP","87200173","CDM",,,,,,,"facility","outpatient",,,,"337","337",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ INTERMEDIATE JOINT/BURSA W/O US BIL","87200175","CDM","510","RC","20605","HCPCS",,,"facility","outpatient",,,"50","2712","2712",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CMPTR OPHTH IMG OPT NERVE BILAT","87200176","CDM","510","RC","92133","HCPCS",,,"facility","inpatient",,,,"326","326",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CMPTR OPHTH IMG OPT NERVE BILAT","87200176","CDM","510","RC","92133","HCPCS",,,"facility","outpatient",,,,"326","326",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPTR OPHTH DX IMG POST SG BILAT","87200177","CDM","510","RC","92134","HCPCS",,,"facility","inpatient",,,,"276","276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPTR OPHTH DX IMG POST SG BILAT","87200177","CDM","510","RC","92134","HCPCS",,,"facility","outpatient",,,,"276","276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AC PARACENTESIS RML AQUEOUS","87200190","CDM","510","RC","65800","HCPCS",,,"facility","inpatient",,,,"7608","7608",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG AC PARACENTESIS RML AQUEOUS","87200190","CDM","510","RC","65800","HCPCS",,,"facility","outpatient",,,,"7608","7608",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THORACENTESIS WO IMAGING","87200195","CDM","510","RC","32554","HCPCS",,,"facility","inpatient",,,,"3229","3229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THORACENTESIS WO IMAGING","87200195","CDM","510","RC","32554","HCPCS",,,"facility","outpatient",,,,"3229","3229",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THORACENTESIS W/IMAGING","87200200","CDM","510","RC","32555","HCPCS",,,"facility","inpatient",,,,"3790","3790",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG THORACENTESIS W/IMAGING","87200200","CDM","510","RC","32555","HCPCS",,,"facility","outpatient",,,,"3790","3790",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMV TUNN CV CATH W/O PT","87200207","CDM","510","RC","36589","HCPCS",,,"facility","inpatient",,,,"4713","4713",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMV TUNN CV CATH W/O PT","87200207","CDM","510","RC","36589","HCPCS",,,"facility","outpatient",,,,"4713","4713",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARENT INFANT PROGRAM HOME VISIT","87200210","CDM",,,,,,,"facility","inpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARENT INFANT PROGRAM HOME VISIT","87200210","CDM",,,,,,,"facility","outpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARENT INFANT PROGRAM CENTER VISIT","87200211","CDM",,,,,,,"facility","inpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARENT INFANT PROGRAM CENTER VISIT","87200211","CDM",,,,,,,"facility","outpatient",,,,"109","109",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARENT INFANT PROGRAM BATELLE DEV INVENTORY","87200212","CDM",,,,,,,"facility","inpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARENT INFANT PROGRAM BATELLE DEV INVENTORY","87200212","CDM",,,,,,,"facility","outpatient",,,,"146","146",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT NON-TUNN CV CATH<5","87200222","CDM","510","RC","36555","HCPCS",,,"facility","inpatient",,,,"1485","1485",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT NON-TUNN CV CATH<5","87200222","CDM","510","RC","36555","HCPCS",,,"facility","outpatient",,,,"1485","1485",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RPLC COMP NON-TUN CV CATH","87200223","CDM","510","RC","36580","HCPCS",,,"facility","inpatient",,,,"12100","12100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RPLC COMP NON-TUN CV CATH","87200223","CDM","510","RC","36580","HCPCS",,,"facility","outpatient",,,,"12100","12100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE PICC WO PORT SAME ACCESS W/ S&I","87200224","CDM","510","RC","36584","HCPCS",,,"facility","inpatient",,,,"4578","4578",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPLACE PICC WO PORT SAME ACCESS W/ S&I","87200224","CDM","510","RC","36584","HCPCS",,,"facility","outpatient",,,,"4578","4578",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPR CV CATH W/O PORT","87200226","CDM","510","RC","36575","HCPCS",,,"facility","inpatient",,,,"3942","3942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPR CV CATH W/O PORT","87200226","CDM","510","RC","36575","HCPCS",,,"facility","outpatient",,,,"3942","3942",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX MUSCLE SUPERFICIAL","87200235","CDM","510","RC","20200","HCPCS",,,"facility","inpatient",,,,"14211","14211",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX MUSCLE SUPERFICIAL","87200235","CDM","510","RC","20200","HCPCS",,,"facility","outpatient",,,,"14211","14211",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INF CHEM INTRA ART PROLNG","87200238","CDM","335","RC","96425","HCPCS",,,"facility","inpatient",,,,"1594","1594",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INF CHEM INTRA ART PROLNG","87200238","CDM","335","RC","96425","HCPCS",,,"facility","outpatient",,,,"1594","1594",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BASED CLINIC INJS ANES/STRD IMG TFRML EDRL LMBR/SAC 1 LVL BIL","87200240","CDM","510","RC","64483","HCPCS",,,"facility","outpatient",,,"50","7352","7352",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CHEMO PLURAL CAV W/THOR","87200246","CDM","335","RC","96440","HCPCS",,,"facility","inpatient",,,,"3403","3403",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO PLURAL CAV W/THOR","87200246","CDM","335","RC","96440","HCPCS",,,"facility","outpatient",,,,"3403","3403",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORESCEIN ANGIOGRAPHY LT","87200257","CDM","510","RC","92235","HCPCS",,,"facility","inpatient",,,"LT","1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG FLUORESCEIN ANGIOGRAPHY LT","87200257","CDM","510","RC","92235","HCPCS",,,"facility","outpatient",,,"LT","1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG FLUORSCEIN ANGIOGRAPHY RT","87200258","CDM","510","RC","92235","HCPCS",,,"facility","inpatient",,,"RT","1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG FLUORSCEIN ANGIOGRAPHY RT","87200258","CDM","510","RC","92235","HCPCS",,,"facility","outpatient",,,"RT","1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG FLUORESCEIN ANGIOGRAPHY BI","87200259","CDM","510","RC","92235","HCPCS",,,"facility","inpatient",,,,"1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORESCEIN ANGIOGRAPHY BI","87200259","CDM","510","RC","92235","HCPCS",,,"facility","outpatient",,,,"1463","1463",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTMD RPR S/A/T/EXT 7.6-12.5 CM","87200261","CDM","510","RC","12034","HCPCS",,,"facility","inpatient",,,,"2096","2096",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTMD RPR S/A/T/EXT 7.6-12.5 CM","87200261","CDM","510","RC","12034","HCPCS",,,"facility","outpatient",,,,"2096","2096",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CONTACT LENS FIT FOR TX LT","87200262","CDM","510","RC","92071","HCPCS",,,"facility","inpatient",,,"LT","608","608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CONTACT LENS FIT FOR TX LT","87200262","CDM","510","RC","92071","HCPCS",,,"facility","outpatient",,,"LT","608","608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CONTACT LENS FIT FOR TX RT","87200263","CDM","510","RC","92071","HCPCS",,,"facility","inpatient",,,"RT","608","608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CONTACT LENS FIT FOR TX RT","87200263","CDM","510","RC","92071","HCPCS",,,"facility","outpatient",,,"RT","608","608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CONTACT LENS FIT FOR TX BI","87200264","CDM","510","RC","92071","HCPCS",,,"facility","inpatient",,,"50","912","912",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CONTACT LENS FIT FOR TX BI","87200264","CDM","510","RC","92071","HCPCS",,,"facility","outpatient",,,"50","912","912",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PROBE LACRIMAL CANALICULI LT","87200272","CDM","510","RC","68840","HCPCS",,,"facility","inpatient",,,"LT","2445","2445",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PROBE LACRIMAL CANALICULI LT","87200272","CDM","510","RC","68840","HCPCS",,,"facility","outpatient",,,"LT","2445","2445",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG GONIOSCOPY","87200274","CDM","510","RC","92020","HCPCS",,,"facility","inpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GONIOSCOPY","87200274","CDM","510","RC","92020","HCPCS",,,"facility","outpatient",,,,"228","228",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARACENT EYE RMVL BLOOD","87200275","CDM","510","RC","65815","HCPCS",,,"facility","inpatient",,,,"1898","1898",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARACENT EYE RMVL BLOOD","87200275","CDM","510","RC","65815","HCPCS",,,"facility","outpatient",,,,"1898","1898",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TARSORRHAPHY","87200276","CDM","510","RC","67880","HCPCS",,,"facility","inpatient",,,,"10647","10647",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TARSORRHAPHY","87200276","CDM","510","RC","67880","HCPCS",,,"facility","outpatient",,,,"10647","10647",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS EPSDT: CASE CONF, PHYS/DENTIST-PER CASE","87200283","CDM",,,,,,,"facility","inpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS EPSDT: CASE CONF, PHYS/DENTIST-PER CASE","87200283","CDM",,,,,,,"facility","outpatient",,,,"130","130",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS CASE CONF-ALLIED HEALTH-PER QT HR","87200284","CDM",,,,,,,"facility","inpatient",,,,"40","40",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS CASE CONF-ALLIED HEALTH-PER QT HR","87200284","CDM",,,,,,,"facility","outpatient",,,,"40","40",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS PATIENT REPORT-COMPLEX/COMPREHENSIVE","87200285","CDM",,,,,,,"facility","inpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS PATIENT REPORT-COMPLEX/COMPREHENSIVE","87200285","CDM",,,,,,,"facility","outpatient",,,,"142","142",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS ASESS/INTRVN ALLD 30M","87200286","CDM",,,,,,,"facility","inpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CCS ASESS/INTRVN ALLD 30M","87200286","CDM",,,,,,,"facility","outpatient",,,,"129","129",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX OF ANORECTAL WALL ANAL APPROACH","87200292","CDM","510","RC","45100","HCPCS",,,"facility","inpatient",,,,"12763","12763",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BX OF ANORECTAL WALL ANAL APPROACH","87200292","CDM","510","RC","45100","HCPCS",,,"facility","outpatient",,,,"12763","12763",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REFILL MAIN IMPLT PUMP/RSVR DELIVERY SPINE/BRAIN","87200335","CDM","510","RC","95991","HCPCS",,,"facility","inpatient",,,,"1619","1619",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REFILL MAIN IMPLT PUMP/RSVR DELIVERY SPINE/BRAIN","87200335","CDM","510","RC","95991","HCPCS",,,"facility","outpatient",,,,"1619","1619",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 1","87200360","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 1","87200360","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"131","131",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 2","87200361","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 2","87200361","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"183","183",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 3","87200362","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"235","235",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 3","87200362","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"235","235",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 4","87200363","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"287","287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 4","87200363","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"287","287",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 5","87200364","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,,"339","339",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LACTATION CLINIC VISIT LEVEL 5","87200364","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,,"339","339",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARPAL TUNNEL  TX  INJ","87200365","CDM","510","RC","20526","HCPCS",,,"facility","inpatient",,,,"1391","1391",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CARPAL TUNNEL  TX  INJ","87200365","CDM","510","RC","20526","HCPCS",,,"facility","outpatient",,,,"1391","1391",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY EDUCATIONAL THERAPY EVALUATION PER HOUR","87200380","CDM",,,,,,,"facility","inpatient",,,,"300","300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY EDUCATIONAL THERAPY EVALUATION PER HOUR","87200380","CDM",,,,,,,"facility","outpatient",,,,"300","300",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY PARENT EDUCATION/TRAINING","87200387","CDM",,,,,,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY PARENT EDUCATION/TRAINING","87200387","CDM",,,,,,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HANEN/GGRC","87200388","CDM",,,,,,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HANEN/GGRC","87200388","CDM",,,,,,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CL TX ARTFX MCP/IP  JOINT W/MANIP","87200389","CDM","510","RC","26742","HCPCS",,,"facility","inpatient",,,,"4053","4053",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CL TX ARTFX MCP/IP  JOINT W/MANIP","87200389","CDM","510","RC","26742","HCPCS",,,"facility","outpatient",,,,"4053","4053",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIVER ELASTOGRAPHY","87200390","CDM","510","RC","91200","HCPCS",,,"facility","inpatient",,,,"772","772",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LIVER ELASTOGRAPHY","87200390","CDM","510","RC","91200","HCPCS",,,"facility","outpatient",,,,"772","772",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY SOCIAL SKILLS GROUP","87200393","CDM",,,,,,,"facility","inpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG S-PAY SOCIAL SKILLS GROUP","87200393","CDM",,,,,,,"facility","outpatient",,,,"104","104",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CMPTR OPHTH IMG OPT NERVE LT","87200407","CDM","510","RC","92133","HCPCS",,,"facility","inpatient",,,"LT","326","326",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CMPTR OPHTH IMG OPT NERVE LT","87200407","CDM","510","RC","92133","HCPCS",,,"facility","outpatient",,,"LT","326","326",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CMPTR OPHTH IMG OPT NERVE RT","87200408","CDM","510","RC","92133","HCPCS",,,"facility","inpatient",,,"RT","326","326",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CMPTR OPHTH IMG OPT NERVE RT","87200408","CDM","510","RC","92133","HCPCS",,,"facility","outpatient",,,"RT","326","326",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG EXTERNAL VERSION","87200412","CDM","510","RC","59412","HCPCS",,,"facility","inpatient",,,,"2750","2750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXTERNAL VERSION","87200412","CDM","510","RC","59412","HCPCS",,,"facility","outpatient",,,,"2750","2750",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INDOCYANINE GREEN ANGIOGRAPHY LT","87200414","CDM","510","RC","92240","HCPCS",,,"facility","inpatient",,,"LT","985","985",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INDOCYANINE GREEN ANGIOGRAPHY LT","87200414","CDM","510","RC","92240","HCPCS",,,"facility","outpatient",,,"LT","985","985",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INDOCYANINE GREEN ANGIOGRAPHY RT","87200415","CDM","510","RC","92240","HCPCS",,,"facility","inpatient",,,"RT","985","985",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INDOCYANINE GREEN ANGIOGRAPHY RT","87200415","CDM","510","RC","92240","HCPCS",,,"facility","outpatient",,,"RT","985","985",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INJ PVB THORACIC SINGLE SITE","87200418","CDM","510","RC","64461","HCPCS",,,"facility","outpatient",,,,"3517","3517",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ PVB THORACIC 2ND+ SITE","87200419","CDM","510","RC","64462","HCPCS",,,"facility","outpatient",,,,"1753","1753",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PVB THORACIC CONT INFUSION","87200420","CDM","510","RC","64463","HCPCS",,,"facility","outpatient",,,,"2173","2173",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRABECULOPLASTY LASER LT","87200421","CDM","510","RC","65855","HCPCS",,,"facility","inpatient",,,"LT","3804","3804",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TRABECULOPLASTY LASER LT","87200421","CDM","510","RC","65855","HCPCS",,,"facility","outpatient",,,"LT","3804","3804",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TRABECULOPLASTY LASER RT","87200422","CDM","510","RC","65855","HCPCS",,,"facility","inpatient",,,"RT","3804","3804",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TRABECULOPLASTY LASER RT","87200422","CDM","510","RC","65855","HCPCS",,,"facility","outpatient",,,"RT","3804","3804",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RVSN IRIS LASR EA SESSION LT","87200423","CDM","510","RC","66761","HCPCS",,,"facility","inpatient",,,"LT","3913","3913",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG RVSN IRIS LASR EA SESSION LT","87200423","CDM","510","RC","66761","HCPCS",,,"facility","outpatient",,,"LT","3913","3913",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG RVSN IRIS LASR EA SESSION RT","87200424","CDM","510","RC","66761","HCPCS",,,"facility","inpatient",,,"RT","3913","3913",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RVSN IRIS LASR EA SESSION RT","87200424","CDM","510","RC","66761","HCPCS",,,"facility","outpatient",,,"RT","3913","3913",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG DISCISSN 2ND MEM CAT LASR LT","87200425","CDM","510","RC","66821","HCPCS",,,"facility","inpatient",,,"LT","3867","3867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DISCISSN 2ND MEM CAT LASR LT","87200425","CDM","510","RC","66821","HCPCS",,,"facility","outpatient",,,"LT","3867","3867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DISCISSN 2ND MEM CAT LASR RT","87200426","CDM","510","RC","66821","HCPCS",,,"facility","inpatient",,,"RT","3867","3867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG DISCISSN 2ND MEM CAT LASR RT","87200426","CDM","510","RC","66821","HCPCS",,,"facility","outpatient",,,"RT","3867","3867",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RET LES PHOTOCOAGULATION LT","87200427","CDM","510","RC","67210","HCPCS",,,"facility","inpatient",,,"LT","5947","5947",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG RET LES PHOTOCOAGULATION LT","87200427","CDM","510","RC","67210","HCPCS",,,"facility","outpatient",,,"LT","5947","5947",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG RET LES PHOTOCOAGULATION RT","87200428","CDM","510","RC","67210","HCPCS",,,"facility","inpatient",,,"RT","5947","5947",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RET LES PHOTOCOAGULATION RT","87200428","CDM","510","RC","67210","HCPCS",,,"facility","outpatient",,,"RT","5947","5947",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REMOVE FB EYE CONJ EMBED LT","87200429","CDM","510","RC","65210","HCPCS",,,"facility","inpatient",,,"LT","1503","1503",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG REMOVE FB EYE CONJ EMBED LT","87200429","CDM","510","RC","65210","HCPCS",,,"facility","outpatient",,,"LT","1503","1503",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG REMOVE FB EYE CONJ EMBED RT","87200430","CDM","510","RC","65210","HCPCS",,,"facility","inpatient",,,"RT","1503","1503",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REMOVE FB EYE CONJ EMBED RT","87200430","CDM","510","RC","65210","HCPCS",,,"facility","outpatient",,,"RT","1503","1503",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RMV FB EYE CORN W LAMP LT","87200431","CDM","510","RC","65222","HCPCS",,,"facility","inpatient",,,"LT","965","965",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG RMV FB EYE CORN W LAMP LT","87200431","CDM","510","RC","65222","HCPCS",,,"facility","outpatient",,,"LT","965","965",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG RMV FB EYE CORN W LAMP RT","87200432","CDM","510","RC","65222","HCPCS",,,"facility","inpatient",,,"RT","965","965",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RMV FB EYE CORN W LAMP RT","87200432","CDM","510","RC","65222","HCPCS",,,"facility","outpatient",,,"RT","965","965",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INTRAVITREAL IJ DRUG LT","87200433","CDM","510","RC","67028","HCPCS",,,"facility","inpatient",,,"LT","2626","2626",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INTRAVITREAL IJ DRUG LT","87200433","CDM","510","RC","67028","HCPCS",,,"facility","outpatient",,,"LT","2626","2626",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INTRAVITREAL IJ DRUG RT","87200434","CDM","510","RC","67028","HCPCS",,,"facility","inpatient",,,"RT","2626","2626",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INTRAVITREAL IJ DRUG RT","87200434","CDM","510","RC","67028","HCPCS",,,"facility","outpatient",,,"RT","2626","2626",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TENON'S CAPSULE INJECTION LT","87200435","CDM","510","RC","67515","HCPCS",,,"facility","inpatient",,,"LT","2992","2992",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TENON'S CAPSULE INJECTION LT","87200435","CDM","510","RC","67515","HCPCS",,,"facility","outpatient",,,"LT","2992","2992",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TENON'S CAPSULE INJECTION RT","87200436","CDM","510","RC","67515","HCPCS",,,"facility","inpatient",,,"RT","2992","2992",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TENON'S CAPSULE INJECTION RT","87200436","CDM","510","RC","67515","HCPCS",,,"facility","outpatient",,,"RT","2992","2992",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INCISIONAL BIOPSY EYELID SKIN & LID MARGIN LT","87200437","CDM","510","RC","67810","HCPCS",,,"facility","inpatient",,,"LT","962","962",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INCISIONAL BIOPSY EYELID SKIN & LID MARGIN LT","87200437","CDM","510","RC","67810","HCPCS",,,"facility","outpatient",,,"LT","962","962",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INCISIONAL BIOPSY EYELID SKIN & LID MARGIN RT","87200438","CDM","510","RC","67810","HCPCS",,,"facility","inpatient",,,"RT","962","962",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INCISIONAL BIOPSY EYELID SKIN & LID MARGIN RT","87200438","CDM","510","RC","67810","HCPCS",,,"facility","outpatient",,,"RT","962","962",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TRICH EPILATION FORCEPS LT","87200439","CDM","510","RC","67820","HCPCS",,,"facility","inpatient",,,"LT","1009","1009",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TRICH EPILATION FORCEPS LT","87200439","CDM","510","RC","67820","HCPCS",,,"facility","outpatient",,,"LT","1009","1009",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TRICH EPILATION FORCEPS RT","87200440","CDM","510","RC","67820","HCPCS",,,"facility","inpatient",,,"RT","1009","1009",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TRICH EPILATION FORCEPS RT","87200440","CDM","510","RC","67820","HCPCS",,,"facility","outpatient",,,"RT","1009","1009",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG SUBCONJUNCTIVAL INJECTION LT","87200441","CDM","510","RC","68200","HCPCS",,,"facility","inpatient",,,"LT","2010","2010",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG SUBCONJUNCTIVAL INJECTION LT","87200441","CDM","510","RC","68200","HCPCS",,,"facility","outpatient",,,"LT","2010","2010",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG SUBCONJUNCTIVAL INJECTION RT","87200442","CDM","510","RC","68200","HCPCS",,,"facility","inpatient",,,"RT","2010","2010",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG SUBCONJUNCTIVAL INJECTION RT","87200442","CDM","510","RC","68200","HCPCS",,,"facility","outpatient",,,"RT","2010","2010",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INCIS/DRN LACRIMAL GLAND LT","87200443","CDM","510","RC","68400","HCPCS",,,"facility","inpatient",,,"LT","7189","7189",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INCIS/DRN LACRIMAL GLAND LT","87200443","CDM","510","RC","68400","HCPCS",,,"facility","outpatient",,,"LT","7189","7189",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INCIS/DRN LACRIMAL GLAND RT","87200444","CDM","510","RC","68400","HCPCS",,,"facility","inpatient",,,"RT","7189","7189",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INCIS/DRN LACRIMAL GLAND RT","87200444","CDM","510","RC","68400","HCPCS",,,"facility","outpatient",,,"RT","7189","7189",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG LACR PUNCT CLOSUR EA PLUG LT","87200445","CDM","510","RC","68761","HCPCS",,,"facility","inpatient",,,"LT","3968","3968",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG LACR PUNCT CLOSUR EA PLUG LT","87200445","CDM","510","RC","68761","HCPCS",,,"facility","outpatient",,,"LT","3968","3968",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG LACR PUNCT CLOSUR EA PLUG RT","87200446","CDM","510","RC","68761","HCPCS",,,"facility","inpatient",,,"RT","3968","3968",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG LACR PUNCT CLOSUR EA PLUG RT","87200446","CDM","510","RC","68761","HCPCS",,,"facility","outpatient",,,"RT","3968","3968",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CHEMODNRV MUSC-MUSC INNERVATED FACIAL NRV LT","87200447","CDM","510","RC","64612","HCPCS",,,"facility","inpatient",,,"LT","1195","1195",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CHEMODNRV MUSC-MUSC INNERVATED FACIAL NRV LT","87200447","CDM","510","RC","64612","HCPCS",,,"facility","outpatient",,,"LT","1195","1195",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CHEMODNRV MUSC-MUSC INNERVATED FACIAL NRV RT","87200448","CDM","510","RC","64612","HCPCS",,,"facility","inpatient",,,"RT","1195","1195",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CHEMODNRV MUSC-MUSC INNERVATED FACIAL NRV RT","87200448","CDM","510","RC","64612","HCPCS",,,"facility","outpatient",,,"RT","1195","1195",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CHEMO DENERV EXTROC MUSC LT","87200449","CDM","510","RC","67345","HCPCS",,,"facility","inpatient",,,"LT","3027","3027",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CHEMO DENERV EXTROC MUSC LT","87200449","CDM","510","RC","67345","HCPCS",,,"facility","outpatient",,,"LT","3027","3027",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CHEMO DENERV EXTROC MUSC RT","87200450","CDM","510","RC","67345","HCPCS",,,"facility","inpatient",,,"RT","3027","3027",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CHEMO DENERV EXTROC MUSC RT","87200450","CDM","510","RC","67345","HCPCS",,,"facility","outpatient",,,"RT","3027","3027",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BIOPSY CONJUNCTIVA LT","87200451","CDM","510","RC","68100","HCPCS",,,"facility","inpatient",,,"LT","10223","10223",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BIOPSY CONJUNCTIVA LT","87200451","CDM","510","RC","68100","HCPCS",,,"facility","outpatient",,,"LT","10223","10223",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BIOPSY CONJUNCTIVA RT","87200452","CDM","510","RC","68100","HCPCS",,,"facility","inpatient",,,"RT","10223","10223",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BIOPSY CONJUNCTIVA RT","87200452","CDM","510","RC","68100","HCPCS",,,"facility","outpatient",,,"RT","10223","10223",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REMOVE FB EYE CONJ SUPERF LT","87200453","CDM","510","RC","65205","HCPCS",,,"facility","inpatient",,,"LT","676","676",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG REMOVE FB EYE CONJ SUPERF LT","87200453","CDM","510","RC","65205","HCPCS",,,"facility","outpatient",,,"LT","676","676",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG REMOVE FB EYE CONJ SUPERF RT","87200454","CDM","510","RC","65205","HCPCS",,,"facility","inpatient",,,"RT","676","676",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REMOVE FB EYE CONJ SUPERF RT","87200454","CDM","510","RC","65205","HCPCS",,,"facility","outpatient",,,"RT","676","676",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REMV FB CORNEAL W/O LAMP LT","87200455","CDM","510","RC","65220","HCPCS",,,"facility","inpatient",,,"LT","989","989",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG REMV FB CORNEAL W/O LAMP LT","87200455","CDM","510","RC","65220","HCPCS",,,"facility","outpatient",,,"LT","989","989",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG REMV FB CORNEAL W/O LAMP RT","87200456","CDM","510","RC","65220","HCPCS",,,"facility","inpatient",,,"RT","989","989",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REMV FB CORNEAL W/O LAMP RT","87200456","CDM","510","RC","65220","HCPCS",,,"facility","outpatient",,,"RT","989","989",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BIOPSY CORNEA LT","87200457","CDM","510","RC","65410","HCPCS",,,"facility","inpatient",,,"LT","14915","14915",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BIOPSY CORNEA LT","87200457","CDM","510","RC","65410","HCPCS",,,"facility","outpatient",,,"LT","14915","14915",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BIOPSY CORNEA RT","87200458","CDM","510","RC","65410","HCPCS",,,"facility","inpatient",,,"RT","14915","14915",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BIOPSY CORNEA RT","87200458","CDM","510","RC","65410","HCPCS",,,"facility","outpatient",,,"RT","14915","14915",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG EXCISION PTERYGIUM LT","87200459","CDM","510","RC","65420","HCPCS",,,"facility","inpatient",,,"LT","7608","7608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG EXCISION PTERYGIUM LT","87200459","CDM","510","RC","65420","HCPCS",,,"facility","outpatient",,,"LT","7608","7608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG EXCISION PTERYGIUM RT","87200460","CDM","510","RC","65420","HCPCS",,,"facility","inpatient",,,"RT","7608","7608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG EXCISION PTERYGIUM RT","87200460","CDM","510","RC","65420","HCPCS",,,"facility","outpatient",,,"RT","7608","7608",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CORNEAL SCRAPING DX LT","87200461","CDM","510","RC","65430","HCPCS",,,"facility","inpatient",,,"LT","4768","4768",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CORNEAL SCRAPING DX LT","87200461","CDM","510","RC","65430","HCPCS",,,"facility","outpatient",,,"LT","4768","4768",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CORNEAL SCRAPING DX RT","87200462","CDM","510","RC","65430","HCPCS",,,"facility","inpatient",,,"RT","4768","4768",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CORNEAL SCRAPING DX RT","87200462","CDM","510","RC","65430","HCPCS",,,"facility","outpatient",,,"RT","4768","4768",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CYCLOPHOTCOAG TRANSSCLERL LT","87200463","CDM","510","RC","66710","HCPCS",,,"facility","inpatient",,,"LT","14083","14083",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CYCLOPHOTCOAG TRANSSCLERL LT","87200463","CDM","510","RC","66710","HCPCS",,,"facility","outpatient",,,"LT","14083","14083",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CYCLOPHOTCOAG TRANSSCLERL RT","87200464","CDM","510","RC","66710","HCPCS",,,"facility","inpatient",,,"RT","14083","14083",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CYCLOPHOTCOAG TRANSSCLERL RT","87200464","CDM","510","RC","66710","HCPCS",,,"facility","outpatient",,,"RT","14083","14083",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REPR RETINL DETACH AIR IJ LT","87200465","CDM","510","RC","67110","HCPCS",,,"facility","inpatient",,,"LT","14411","14411",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG REPR RETINL DETACH AIR IJ LT","87200465","CDM","510","RC","67110","HCPCS",,,"facility","outpatient",,,"LT","14411","14411",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG REPR RETINL DETACH AIR IJ RT","87200466","CDM","510","RC","67110","HCPCS",,,"facility","inpatient",,,"RT","14411","14411",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG REPR RETINL DETACH AIR IJ RT","87200466","CDM","510","RC","67110","HCPCS",,,"facility","outpatient",,,"RT","14411","14411",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PROPH RET DETACH CRYO/DIA LT","87200467","CDM","510","RC","67141","HCPCS",,,"facility","inpatient",,,"LT","13890","13890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PROPH RET DETACH CRYO/DIA LT","87200467","CDM","510","RC","67141","HCPCS",,,"facility","outpatient",,,"LT","13890","13890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PROPH RET DETACH CRYO/DIA RT","87200468","CDM","510","RC","67141","HCPCS",,,"facility","inpatient",,,"RT","13890","13890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PROPH RET DETACH CRYO/DIA RT","87200468","CDM","510","RC","67141","HCPCS",,,"facility","outpatient",,,"RT","13890","13890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PROPH RET DETCH PHOTOCOAG LT","87200469","CDM","510","RC","67145","HCPCS",,,"facility","inpatient",,,"LT","5293","5293",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PROPH RET DETCH PHOTOCOAG LT","87200469","CDM","510","RC","67145","HCPCS",,,"facility","outpatient",,,"LT","5293","5293",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PROPH RET DETCH PHOTOCOAG RT","87200470","CDM","510","RC","67145","HCPCS",,,"facility","inpatient",,,"RT","5293","5293",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PROPH RET DETCH PHOTOCOAG RT","87200470","CDM","510","RC","67145","HCPCS",,,"facility","outpatient",,,"RT","5293","5293",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG DSTRCT RETNL LSN CRYO/DIA LT","87200471","CDM","510","RC","67208","HCPCS",,,"facility","inpatient",,,"LT","13890","13890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DSTRCT RETNL LSN CRYO/DIA LT","87200471","CDM","510","RC","67208","HCPCS",,,"facility","outpatient",,,"LT","13890","13890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DSTRCT RETNL LSN CRYO/DIA RT","87200472","CDM","510","RC","67208","HCPCS",,,"facility","inpatient",,,"RT","13890","13890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG DSTRCT RETNL LSN CRYO/DIA RT","87200472","CDM","510","RC","67208","HCPCS",,,"facility","outpatient",,,"RT","13890","13890",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TX RTNPTHY PHOTOCOAGULATN LT","87200473","CDM","510","RC","67228","HCPCS",,,"facility","inpatient",,,"LT","3971","3971",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TX RTNPTHY PHOTOCOAGULATN LT","87200473","CDM","510","RC","67228","HCPCS",,,"facility","outpatient",,,"LT","3971","3971",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TX RTNPTHY PHOTOCOAGULATN RT","87200474","CDM","510","RC","67228","HCPCS",,,"facility","inpatient",,,"RT","3971","3971",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TX RTNPTHY PHOTOCOAGULATN RT","87200474","CDM","510","RC","67228","HCPCS",,,"facility","outpatient",,,"RT","3971","3971",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TRICH EPILATION OTHER LT","87200477","CDM","510","RC","67825","HCPCS",,,"facility","inpatient",,,"LT","2337","2337",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TRICH EPILATION OTHER LT","87200477","CDM","510","RC","67825","HCPCS",,,"facility","outpatient",,,"LT","2337","2337",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG TRICH EPILATION OTHER RT","87200478","CDM","510","RC","67825","HCPCS",,,"facility","inpatient",,,"RT","2337","2337",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TRICH EPILATION OTHER RT","87200478","CDM","510","RC","67825","HCPCS",,,"facility","outpatient",,,"RT","2337","2337",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INCISION CONJUNCTIVA LT","87200479","CDM","510","RC","68020","HCPCS",,,"facility","inpatient",,,"LT","4445","4445",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INCISION CONJUNCTIVA LT","87200479","CDM","510","RC","68020","HCPCS",,,"facility","outpatient",,,"LT","4445","4445",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG INCISION CONJUNCTIVA RT","87200480","CDM","510","RC","68020","HCPCS",,,"facility","inpatient",,,"RT","4445","4445",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG INCISION CONJUNCTIVA RT","87200480","CDM","510","RC","68020","HCPCS",,,"facility","outpatient",,,"RT","4445","4445",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BIOPSY OF LACRIMAL SAC LT","87200483","CDM","510","RC","68525","HCPCS",,,"facility","inpatient",,,"LT","18580","18580",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BIOPSY OF LACRIMAL SAC LT","87200483","CDM","510","RC","68525","HCPCS",,,"facility","outpatient",,,"LT","18580","18580",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG BIOPSY OF LACRIMAL SAC RT","87200484","CDM","510","RC","68525","HCPCS",,,"facility","inpatient",,,"RT","18580","18580",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BIOPSY OF LACRIMAL SAC RT","87200484","CDM","510","RC","68525","HCPCS",,,"facility","outpatient",,,"RT","18580","18580",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG DIL TEAR DUCT OPENING LT","87200485","CDM","510","RC","68801","HCPCS",,,"facility","inpatient",,,"LT","1769","1769",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DIL TEAR DUCT OPENING LT","87200485","CDM","510","RC","68801","HCPCS",,,"facility","outpatient",,,"LT","1769","1769",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DIL TEAR DUCT OPENING RT","87200486","CDM","510","RC","68801","HCPCS",,,"facility","inpatient",,,"RT","1769","1769",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG DIL TEAR DUCT OPENING RT","87200486","CDM","510","RC","68801","HCPCS",,,"facility","outpatient",,,"RT","1769","1769",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PROBE NASOLACRIMAL DUCT LT","87200487","CDM","510","RC","68810","HCPCS",,,"facility","inpatient",,,"LT","3039","3039",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PROBE NASOLACRIMAL DUCT LT","87200487","CDM","510","RC","68810","HCPCS",,,"facility","outpatient",,,"LT","3039","3039",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG PROBE NASOLACRIMAL DUCT RT","87200488","CDM","510","RC","68810","HCPCS",,,"facility","inpatient",,,"RT","3039","3039",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG PROBE NASOLACRIMAL DUCT RT","87200488","CDM","510","RC","68810","HCPCS",,,"facility","outpatient",,,"RT","3039","3039",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TEMPORARY CLOSURE OF EYELIDS BY SUTURE RT","87200489","CDM","510","RC","67875","HCPCS",,,"facility","inpatient",,,"RT","7558","7558",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TEMPORARY CLOSURE OF EYELIDS BY SUTURE RT","87200489","CDM","510","RC","67875","HCPCS",,,"facility","outpatient",,,"RT","7558","7558",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG EXCISION OF LESION CONJUNCTIVA TO 1CM LT","87200491","CDM","510","RC","68110","HCPCS",,,"facility","inpatient",,,"LT","12978","12978",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG EXCISION OF LESION CONJUNCTIVA TO 1CM LT","87200491","CDM","510","RC","68110","HCPCS",,,"facility","outpatient",,,"LT","12978","12978",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG EXCISION OF LESION CONJUNCTIVA TO 1CM RT","87200492","CDM","510","RC","68110","HCPCS",,,"facility","inpatient",,,"RT","12978","12978",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG EXCISION OF LESION CONJUNCTIVA TO 1CM RT","87200492","CDM","510","RC","68110","HCPCS",,,"facility","outpatient",,,"RT","12978","12978",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG OPTIC NERVE DECOMPRESSION LT","87200497","CDM","510","RC","67570","HCPCS",,,"facility","inpatient",,,"LT","91552","91552",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG OPTIC NERVE DECOMPRESSION LT","87200497","CDM","510","RC","67570","HCPCS",,,"facility","outpatient",,,"LT","91552","91552",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG OPTIC NERVE DECOMPRESSION RT","87200498","CDM","510","RC","67570","HCPCS",,,"facility","inpatient",,,"RT","91552","91552",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG OPTIC NERVE DECOMPRESSION RT","87200498","CDM","510","RC","67570","HCPCS",,,"facility","outpatient",,,"RT","91552","91552",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG OPTIC NERVE DECOMPRESSION BI","87200499","CDM","510","RC","67570","HCPCS",,,"facility","inpatient",,,"50","137328","137328",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG OPTIC NERVE DECOMPRESSION BI","87200499","CDM","510","RC","67570","HCPCS",,,"facility","outpatient",,,"50","137328","137328",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG OPHTHALMIC BIOMETRY","87200510","CDM","510","RC","92136","HCPCS",,,"facility","inpatient",,,,"681","681",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPHTHALMIC BIOMETRY","87200510","CDM","510","RC","92136","HCPCS",,,"facility","outpatient",,,,"681","681",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US BI","87200511","CDM","510","RC","20610","HCPCS",,,"facility","outpatient",,,"50","2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US LT","87200515","CDM","510","RC","20610","HCPCS",,,"facility","inpatient",,,"LT","1979","1979",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US LT","87200515","CDM","510","RC","20610","HCPCS",,,"facility","outpatient",,,"LT","1865","1865",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US RT","87200516","CDM","510","RC","20610","HCPCS",,,"facility","inpatient",,,"RT","1979","1979",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG DRAIN/INJ MAJOR JOINT/BURSA W/O US RT","87200516","CDM","510","RC","20610","HCPCS",,,"facility","outpatient",,,"RT","1865","1865",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG BIOPSY SOFT TISSUE LEG/ANKLE DEEP","87200517","CDM","510","RC","27614","HCPCS",,,"facility","inpatient",,,,"9785","9785",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BIOPSY SOFT TISSUE LEG/ANKLE DEEP","87200517","CDM","510","RC","27614","HCPCS",,,"facility","outpatient",,,,"9785","9785",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORESCEIN AND ICG ANGIOGRAPHY BI","87200537","CDM","510","RC","92242","HCPCS",,,"facility","inpatient",,,,"2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORESCEIN AND ICG ANGIOGRAPHY BI","87200537","CDM","510","RC","92242","HCPCS",,,"facility","outpatient",,,,"2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FLUORESCEIN AND ICG ANGIOGRAPHY LT","87200538","CDM","510","RC","92242","HCPCS",,,"facility","inpatient",,,"LT","2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG FLUORESCEIN AND ICG ANGIOGRAPHY LT","87200538","CDM","510","RC","92242","HCPCS",,,"facility","outpatient",,,"LT","2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG FLUORESCEIN AND ICG ANGIOGRAPHY RT","87200539","CDM","510","RC","92242","HCPCS",,,"facility","inpatient",,,"RT","2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG FLUORESCEIN AND ICG ANGIOGRAPHY RT","87200539","CDM","510","RC","92242","HCPCS",,,"facility","outpatient",,,"RT","2798","2798",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG I & D OF BARTHOLIN'S GLAND ABSCESS","87200542","CDM","510","RC","56420","HCPCS",,,"facility","inpatient",,,,"956","956",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG I & D OF BARTHOLIN'S GLAND ABSCESS","87200542","CDM","510","RC","56420","HCPCS",,,"facility","outpatient",,,,"956","956",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG RVSN IRIS PHOTOCOAG 1+ SESSIONS LT","87200554","CDM","510","RC","66762","HCPCS",,,"facility","inpatient",,,"LT","4628","4628",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG RVSN IRIS PHOTOCOAG 1+ SESSIONS LT","87200554","CDM","510","RC","66762","HCPCS",,,"facility","outpatient",,,"LT","4628","4628",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG RVSN IRIS PHOTOCOAG 1+ SESSIONS RT","87200555","CDM","510","RC","66762","HCPCS",,,"facility","inpatient",,,"RT","4628","4628",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RVSN IRIS PHOTOCOAG 1+ SESSIONS RT","87200555","CDM","510","RC","66762","HCPCS",,,"facility","outpatient",,,"RT","4628","4628",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG RVSN IRIS PHOTOCOAG 1+ SESSIONS BIL","87200556","CDM","510","RC","66762","HCPCS",,,"facility","inpatient",,,"50","6942","6942",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG RVSN IRIS PHOTOCOAG 1+ SESSIONS BIL","87200556","CDM","510","RC","66762","HCPCS",,,"facility","outpatient",,,"50","6942","6942",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INSERT IUD","87200557","CDM","510","RC","58300","HCPCS",,,"facility","inpatient",,,"GY","6169","6169",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG INSERT IUD","87200557","CDM","510","RC","58300","HCPCS",,,"facility","outpatient",,,"GY","6169","6169",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"HCHG INSERT PICC <5 YR WO PORT WO IMAGE GUIDANCE","87200564","CDM","510","RC","36568","HCPCS",,,"facility","inpatient",,,,"1663","1663",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC <5 YR WO PORT WO IMAGE GUIDANCE","87200564","CDM","510","RC","36568","HCPCS",,,"facility","outpatient",,,,"1663","1663",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC >=5 YR WO PORT WO IMAGE GUIDANCE","87200565","CDM","510","RC","36569","HCPCS",,,"facility","inpatient",,,,"4451","4451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC >=5 YR WO PORT WO IMAGE GUIDANCE","87200565","CDM","510","RC","36569","HCPCS",,,"facility","outpatient",,,,"4451","4451",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC <5 YR WO PORT W IMAGE GUIDANCE","87200566","CDM","510","RC","36572","HCPCS",,,"facility","inpatient",,,,"3223","3223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC <5 YR WO PORT W IMAGE GUIDANCE","87200566","CDM","510","RC","36572","HCPCS",,,"facility","outpatient",,,,"3223","3223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC >=5 YR WO PORT W IMAGE GUIDANCE","87200567","CDM","510","RC","36573","HCPCS",,,"facility","inpatient",,,,"4995","4995",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT PICC >=5 YR WO PORT W IMAGE GUIDANCE","87200567","CDM","510","RC","36573","HCPCS",,,"facility","outpatient",,,,"4995","4995",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PATTERN ERG W/INTERP & REPORT","87200568","CDM","510","RC","0509T","HCPCS",,,"facility","inpatient",,,,"1087","1087",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PATTERN ERG W/INTERP & REPORT","87200568","CDM","510","RC","0509T","HCPCS",,,"facility","outpatient",,,,"1087","1087",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCH BX SKIN SINGLE LESION","87200571","CDM","510","RC","11104","HCPCS",,,"facility","inpatient",,,,"1223","1223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCH BX SKIN SINGLE LESION","87200571","CDM","510","RC","11104","HCPCS",,,"facility","outpatient",,,,"1019","1019",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCH BX SKIN EA SEPARATE/ADDL LES","87200572","CDM","510","RC","11105","HCPCS",,,"facility","inpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PUNCH BX SKIN EA SEPARATE/ADDL LES","87200572","CDM","510","RC","11105","HCPCS",,,"facility","outpatient",,,,"804","804",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FULL ERG W/INTERP & REPORT","87200577","CDM","510","RC","92273","HCPCS",,,"facility","inpatient",,,,"1372","1372",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG FULL ERG W/INTERP & REPORT","87200577","CDM","510","RC","92273","HCPCS",,,"facility","outpatient",,,,"1372","1372",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MULTIFOCAL ERG W/INTERP & REPORT","87200578","CDM","510","RC","92274","HCPCS",,,"facility","inpatient",,,,"1008","1008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MULTIFOCAL ERG W/INTERP & REPORT","87200578","CDM","510","RC","92274","HCPCS",,,"facility","outpatient",,,,"1008","1008",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BFB TRAINING 1ST 15 MIN","87200593","CDM","510","RC","90912","HCPCS",,,"facility","inpatient",,,,"1040","1040",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BFB TRAINING 1ST 15 MIN","87200593","CDM","510","RC","90912","HCPCS",,,"facility","outpatient",,,,"1040","1040",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BFB TRAINING EA ADDL 15 MIN","87200594","CDM","510","RC","90913","HCPCS",,,"facility","inpatient",,,,"570","570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BFB TRAINING EA ADDL 15 MIN","87200594","CDM","510","RC","90913","HCPCS",,,"facility","outpatient",,,,"570","570",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPSCPY EXTND RTA DRAW & SCL DEPRSN I&R BIL","87200597","CDM","510","RC","92201","HCPCS",,,"facility","inpatient",,,,"329","329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPSCPY EXTND RTA DRAW & SCL DEPRSN I&R BIL","87200597","CDM","510","RC","92201","HCPCS",,,"facility","outpatient",,,,"329","329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPSCPY EXTND OPTIC NRV/MACULA DRAW I&R BIL","87200598","CDM","510","RC","92202","HCPCS",,,"facility","inpatient",,,,"329","329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPSCPY EXTND OPTIC NRV/MACULA DRAW I&R BIL","87200598","CDM","510","RC","92202","HCPCS",,,"facility","outpatient",,,,"329","329",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG OPSCPY EXTND RTA DRAW & SCL DEPRSN I&R LT","87200602","CDM","510","RC","92201","HCPCS",,,"facility","inpatient",,,"LT","329","329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG OPSCPY EXTND RTA DRAW & SCL DEPRSN I&R LT","87200602","CDM","510","RC","92201","HCPCS",,,"facility","outpatient",,,"LT","329","329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG OPSCPY EXTND RTA DRAW & SCL DEPRSN I&R RT","87200603","CDM","510","RC","92201","HCPCS",,,"facility","inpatient",,,"RT","329","329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG OPSCPY EXTND RTA DRAW & SCL DEPRSN I&R RT","87200603","CDM","510","RC","92201","HCPCS",,,"facility","outpatient",,,"RT","329","329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG OPSCPY EXTND OPTIC NRV/MACULA DRAW I&R LT","87200604","CDM","510","RC","92202","HCPCS",,,"facility","inpatient",,,"LT","329","329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG OPSCPY EXTND OPTIC NRV/MACULA DRAW I&R LT","87200604","CDM","510","RC","92202","HCPCS",,,"facility","outpatient",,,"LT","329","329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG OPSCPY EXTND OPTIC NRV/MACULA DRAW I&R RT","87200605","CDM","510","RC","92202","HCPCS",,,"facility","inpatient",,,"RT","329","329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG OPSCPY EXTND OPTIC NRV/MACULA DRAW I&R RT","87200605","CDM","510","RC","92202","HCPCS",,,"facility","outpatient",,,"RT","329","329",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG TH LACTATION CLINIC VISIT LEVEL 1","87200614","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","131","131",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH LACTATION CLINIC VISIT LEVEL 1","87200614","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","131","131",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG  BLADDER INSTILATION CHEMO","87200618","CDM","510","RC","51720","HCPCS",,,"facility","inpatient",,,,"5044","5044",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG  BLADDER INSTILATION CHEMO","87200618","CDM","510","RC","51720","HCPCS",,,"facility","outpatient",,,,"5044","5044",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO CONCURRENT INFUSION","87200619","CDM","335","RC","96549","HCPCS",,,"facility","inpatient",,,,"418","418",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMO CONCURRENT INFUSION","87200619","CDM","335","RC","96549","HCPCS",,,"facility","outpatient",,,,"418","418",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG  I&D OF VULVA OR PERINEAL ABSCESS","87200620","CDM","510","RC","56405","HCPCS",,,"facility","inpatient",,,,"1461","1461",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG  I&D OF VULVA OR PERINEAL ABSCESS","87200620","CDM","510","RC","56405","HCPCS",,,"facility","outpatient",,,,"1461","1461",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DEBRIDE NAIL 1 TO 5","87200634","CDM","510","RC","11720","HCPCS",,,"facility","inpatient",,,,"340","340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DEBRIDE NAIL 1 TO 5","87200634","CDM","510","RC","11720","HCPCS",,,"facility","outpatient",,,,"340","340",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DEBRIDE NAIL 6 OR MORE","87200635","CDM","510","RC","11721","HCPCS",,,"facility","inpatient",,,,"421","421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DEBRIDE NAIL 6 OR MORE","87200635","CDM","510","RC","11721","HCPCS",,,"facility","outpatient",,,,"421","421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ TND SHEATH/LG","87200641","CDM","510","RC","20550","HCPCS",,,"facility","outpatient",,,,"1600","1600",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ TRIGGER PT 1 OR 2 MCL","87200642","CDM","510","RC","20552","HCPCS",,,"facility","outpatient",,,,"1556","1556",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJ TRIGGER PT GT 2 MCL","87200643","CDM","510","RC","20553","HCPCS",,,"facility","outpatient",,,,"1541","1541",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ INTERMEDIATE JOINT/BURSA W/O US","87200644","CDM","510","RC","20605","HCPCS",,,"facility","inpatient",,,,"1808","1808",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ INTERMEDIATE JOINT/BURSA W/O US","87200644","CDM","510","RC","20605","HCPCS",,,"facility","outpatient",,,,"1808","1808",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLADDER IRRIG SMPL","87200648","CDM","510","RC","51700","HCPCS",,,"facility","inpatient",,,,"1421","1421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BLADDER IRRIG SMPL","87200648","CDM","510","RC","51700","HCPCS",,,"facility","outpatient",,,,"1421","1421",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT CATH NONINDWLLNG","87200649","CDM","510","RC","51701","HCPCS",,,"facility","inpatient",,,,"681","681",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT CATH NONINDWLLNG","87200649","CDM","510","RC","51701","HCPCS",,,"facility","outpatient",,,,"681","681",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT CATH TEMP INDWLLNG","87200650","CDM","510","RC","51702","HCPCS",,,"facility","inpatient",,,,"768","768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT CATH TEMP INDWLLNG","87200650","CDM","510","RC","51702","HCPCS",,,"facility","outpatient",,,,"768","768",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT CATH TMP INDWL CMP","87200651","CDM","510","RC","51703","HCPCS",,,"facility","inpatient",,,,"965","965",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERT CATH TMP INDWL CMP","87200651","CDM","510","RC","51703","HCPCS",,,"facility","outpatient",,,,"965","965",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTOMETROGRAM CMPLX","87200652","CDM","510","RC","51726","HCPCS",,,"facility","inpatient",,,,"1800","1800",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYSTOMETROGRAM CMPLX","87200652","CDM","510","RC","51726","HCPCS",,,"facility","outpatient",,,,"1800","1800",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UROFLOWMETRY COMPLEX","87200653","CDM","510","RC","51741","HCPCS",,,"facility","inpatient",,,,"745","745",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG UROFLOWMETRY COMPLEX","87200653","CDM","510","RC","51741","HCPCS",,,"facility","outpatient",,,,"745","745",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG ANAL/URETHRAL NO NDL","87200654","CDM","510","RC","51784","HCPCS",,,"facility","inpatient",,,,"1043","1043",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EMG ANAL/URETHRAL NO NDL","87200654","CDM","510","RC","51784","HCPCS",,,"facility","outpatient",,,,"1043","1043",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VP STUDY INTRAABDOMINAL","87200656","CDM","510","RC","51797","HCPCS",,,"facility","inpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VP STUDY INTRAABDOMINAL","87200656","CDM","510","RC","51797","HCPCS",,,"facility","outpatient",,,,"534","534",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUMBAR PUNCTURE DX","87200657","CDM","510","RC","62270","HCPCS",,,"facility","inpatient",,,,"3056","3056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LUMBAR PUNCTURE DX","87200657","CDM","510","RC","62270","HCPCS",,,"facility","outpatient",,,,"3056","3056",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH LACTATION CLINIC VISIT LEVEL 2","87200675","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","183","183",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH LACTATION CLINIC VISIT LEVEL 2","87200675","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","183","183",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH LACTATION CLINIC VISIT LEVEL 3","87200676","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","235","235",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH LACTATION CLINIC VISIT LEVEL 3","87200676","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","235","235",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH LACTATION CLINIC VISIT LEVEL 4","87200677","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","287","287",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH LACTATION CLINIC VISIT LEVEL 4","87200677","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","287","287",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH LACTATION CLINIC VISIT LEVEL 5","87200679","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","339","339",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH LACTATION CLINIC VISIT LEVEL 5","87200679","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","339","339",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG SKIN SUB GRAFT F/NK/HF/G <=100SQCM 1ST 25SQCM","87200686","CDM","510","RC","15275","HCPCS",,,"facility","inpatient",,,,"5951","5951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SKIN SUB GRAFT F/NK/HF/G <=100SQCM 1ST 25SQCM","87200686","CDM","510","RC","15275","HCPCS",,,"facility","outpatient",,,,"5951","5951",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLP CERVIX W BX & CURETT","87200704","CDM","510","RC","57454","HCPCS",,,"facility","inpatient",,,,"3655","3655",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLP CERVIX W BX & CURETT","87200704","CDM","510","RC","57454","HCPCS",,,"facility","outpatient",,,,"3655","3655",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECLOT VASC DEVICE","87200710","CDM","510","RC","36593","HCPCS",,,"facility","inpatient",,,,"1307","1307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DECLOT VASC DEVICE","87200710","CDM","510","RC","36593","HCPCS",,,"facility","outpatient",,,,"1307","1307",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MED NUTR TX GP EA 30","87200712","CDM","942","RC","97804","HCPCS",,,"facility","inpatient",,,,"38","38",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MED NUTR TX GP EA 30","87200712","CDM","942","RC","97804","HCPCS",,,"facility","outpatient",,,,"38","38",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SKULL SHUNT PUNCTURE","87200719","CDM","510","RC","61070","HCPCS",,,"facility","inpatient",,,,"4540","4540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SKULL SHUNT PUNCTURE","87200719","CDM","510","RC","61070","HCPCS",,,"facility","outpatient",,,,"4540","4540",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRRIG IMPLNTD VNS ACC DVC","87200720","CDM","510","RC","96523","HCPCS",,,"facility","inpatient",,,,"380","380",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IRRIG IMPLNTD VNS ACC DVC","87200720","CDM","510","RC","96523","HCPCS",,,"facility","outpatient",,,,"380","380",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIAGNOSTIC BONE MARROW BIOPSY","87200721","CDM","510","RC","38221","HCPCS",,,"facility","inpatient",,,,"4081","4081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DIAGNOSTIC BONE MARROW BIOPSY","87200721","CDM","510","RC","38221","HCPCS",,,"facility","outpatient",,,,"4081","4081",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLL BLD PICC/CNTRL LN","87200729","CDM","510","RC","36592","HCPCS",,,"facility","inpatient",,,,"526","526",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG COLL BLD PICC/CNTRL LN","87200729","CDM","510","RC","36592","HCPCS",,,"facility","outpatient",,,,"526","526",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC LEVEL 2 W/PROC","87200739","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"25","355","355",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG CLINIC LEVEL 2 W/PROC","87200739","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"25","355","355",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG CLINIC LEVEL 3 W/PROC","87200740","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"25","409","409",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG CLINIC LEVEL 3 W/PROC","87200740","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"25","409","409",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG CLINIC LEVEL 4 W/PROC","87200741","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"25","470","470",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG CLINIC LEVEL 4 W/PROC","87200741","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"25","470","470",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG CLINIC LEVEL 5 W/PROC","87200742","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"25","540","540",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG CLINIC LEVEL 5 W/PROC","87200742","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"25","540","540",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"HCHG CHEMOTX ADMN PRTL CAVITY","87200743","CDM","335","RC","96446","HCPCS",,,"facility","inpatient",,,,"691","691",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMOTX ADMN PRTL CAVITY","87200743","CDM","335","RC","96446","HCPCS",,,"facility","outpatient",,,,"691","691",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALLOGENEIC LYMPHOCYTE INFUSIONS","87200747","CDM","510","RC","38242","HCPCS",,,"facility","inpatient",,,,"5708","5708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ALLOGENEIC LYMPHOCYTE INFUSIONS","87200747","CDM","510","RC","38242","HCPCS",,,"facility","outpatient",,,,"5708","5708",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LAC SMPL/F,E,N 2.5CM/LESS","87200749","CDM","510","RC","12011","HCPCS",,,"facility","inpatient",,,,"1163","1163",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LAC SMPL/F,E,N 2.5CM/LESS","87200749","CDM","510","RC","12011","HCPCS",,,"facility","outpatient",,,,"1163","1163",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL FB SUBQ TISS SMPL","87200758","CDM","510","RC","10120","HCPCS",,,"facility","inpatient",,,,"2055","2055",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVAL FB SUBQ TISS SMPL","87200758","CDM","510","RC","10120","HCPCS",,,"facility","outpatient",,,,"2055","2055",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DRAIN/INJ SMALL JOINT/BURSA W/O US","87200763","CDM","510","RC","20600","HCPCS",,,"facility","outpatient",,,,"1751","1751",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT NON-TUNN CV CATH 5+","87200766","CDM","510","RC","36556","HCPCS",,,"facility","inpatient",,,,"4508","4508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSRT NON-TUNN CV CATH 5+","87200766","CDM","510","RC","36556","HCPCS",,,"facility","outpatient",,,,"4508","4508",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXC FACE-MM B9+MARG 0.6-1.0 CM","87200836","CDM","510","RC","11441","HCPCS",,,"facility","inpatient",,,,"7349","7349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXC FACE-MM B9+MARG 0.6-1.0 CM","87200836","CDM","510","RC","11441","HCPCS",,,"facility","outpatient",,,,"7349","7349",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLY LONG ARM CAST","87200837","CDM","510","RC","29065","HCPCS",,,"facility","inpatient",,,,"606","606",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLY LONG ARM CAST","87200837","CDM","510","RC","29065","HCPCS",,,"facility","outpatient",,,,"606","606",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLY SHORT ARM CAST","87200838","CDM","510","RC","29075","HCPCS",,,"facility","inpatient",,,,"790","790",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLY SHORT ARM CAST","87200838","CDM","510","RC","29075","HCPCS",,,"facility","outpatient",,,,"790","790",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP SPLNT LONG ARM","87200839","CDM","510","RC","29105","HCPCS",,,"facility","inpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP SPLNT LONG ARM","87200839","CDM","510","RC","29105","HCPCS",,,"facility","outpatient",,,,"842","842",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP SPLNT SHRT ARM STA","87200840","CDM","510","RC","29125","HCPCS",,,"facility","inpatient",,,,"875","875",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP SPLNT SHRT ARM STA","87200840","CDM","510","RC","29125","HCPCS",,,"facility","outpatient",,,,"875","875",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP SPLNT FINGER STA","87200841","CDM","510","RC","29130","HCPCS",,,"facility","inpatient",,,,"742","742",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP SPLNT FINGER STA","87200841","CDM","510","RC","29130","HCPCS",,,"facility","outpatient",,,,"742","742",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLY LONG LEG CAST","87200842","CDM","510","RC","29345","HCPCS",,,"facility","inpatient",,,,"954","954",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLY LONG LEG CAST","87200842","CDM","510","RC","29345","HCPCS",,,"facility","outpatient",,,,"954","954",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLY SHORT LEG CAST","87200843","CDM","510","RC","29405","HCPCS",,,"facility","inpatient",,,,"1137","1137",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APPLY SHORT LEG CAST","87200843","CDM","510","RC","29405","HCPCS",,,"facility","outpatient",,,,"1137","1137",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP LONG LEG SPLNT","87200844","CDM","510","RC","29505","HCPCS",,,"facility","inpatient",,,,"926","926",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP LONG LEG SPLNT","87200844","CDM","510","RC","29505","HCPCS",,,"facility","outpatient",,,,"926","926",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP LOW LEG SPLNT","87200845","CDM","510","RC","29515","HCPCS",,,"facility","inpatient",,,,"947","947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APP LOW LEG SPLNT","87200845","CDM","510","RC","29515","HCPCS",,,"facility","outpatient",,,,"947","947",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPR SPICA/BODY CAST/JCKT","87200846","CDM","510","RC","29720","HCPCS",,,"facility","inpatient",,,,"448","448",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REPR SPICA/BODY CAST/JCKT","87200846","CDM","510","RC","29720","HCPCS",,,"facility","outpatient",,,,"448","448",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WINDOWING OF CAST","87200847","CDM","510","RC","29730","HCPCS",,,"facility","inpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG WINDOWING OF CAST","87200847","CDM","510","RC","29730","HCPCS",,,"facility","outpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APHERESIS PLASMA","87200848","CDM","510","RC","36514","HCPCS",,,"facility","inpatient",,,,"7885","7885",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APHERESIS PLASMA","87200848","CDM","510","RC","36514","HCPCS",,,"facility","outpatient",,,,"7885","7885",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PESSARY FITTING/INSERTION","87200851","CDM","510","RC","57160","HCPCS",,,"facility","inpatient",,,,"747","747",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PESSARY FITTING/INSERTION","87200851","CDM","510","RC","57160","HCPCS",,,"facility","outpatient",,,,"747","747",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REMOVE FB EYE CONJ SUPERF BI","87200853","CDM","510","RC","65205","HCPCS",,,"facility","inpatient",,,"50","1014","1014",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG REMOVE FB EYE CONJ SUPERF BI","87200853","CDM","510","RC","65205","HCPCS",,,"facility","outpatient",,,"50","1014","1014",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG REMOVE FB EYE CONJ EMBED BI","87200854","CDM","510","RC","65210","HCPCS",,,"facility","inpatient",,,"50","2254","2254",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG REMOVE FB EYE CONJ EMBED BI","87200854","CDM","510","RC","65210","HCPCS",,,"facility","outpatient",,,"50","2254","2254",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG REMV FB CORNEAL W/O LAMP BI","87200855","CDM","510","RC","65220","HCPCS",,,"facility","inpatient",,,"50","1484","1484",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG REMV FB CORNEAL W/O LAMP BI","87200855","CDM","510","RC","65220","HCPCS",,,"facility","outpatient",,,"50","1484","1484",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG RMV FB EYE CORN W LAMP BI","87200856","CDM","510","RC","65222","HCPCS",,,"facility","inpatient",,,"50","1448","1448",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG RMV FB EYE CORN W LAMP BI","87200856","CDM","510","RC","65222","HCPCS",,,"facility","outpatient",,,"50","1448","1448",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY CORNEA BI","87200857","CDM","510","RC","65410","HCPCS",,,"facility","inpatient",,,"50","22372","22372",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY CORNEA BI","87200857","CDM","510","RC","65410","HCPCS",,,"facility","outpatient",,,"50","22372","22372",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG EXCISION PTERYGIUM BI","87200858","CDM","510","RC","65420","HCPCS",,,"facility","inpatient",,,"50","11412","11412",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG EXCISION PTERYGIUM BI","87200858","CDM","510","RC","65420","HCPCS",,,"facility","outpatient",,,"50","11412","11412",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CORNEAL SCRAPING DX BI","87200859","CDM","510","RC","65430","HCPCS",,,"facility","inpatient",,,"50","7152","7152",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CORNEAL SCRAPING DX BI","87200859","CDM","510","RC","65430","HCPCS",,,"facility","outpatient",,,"50","7152","7152",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TRABECULOPLASTY LASER BI","87200862","CDM","510","RC","65855","HCPCS",,,"facility","inpatient",,,"50","5706","5706",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TRABECULOPLASTY LASER BI","87200862","CDM","510","RC","65855","HCPCS",,,"facility","outpatient",,,"50","5706","5706",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG LASER EYE SEVER ADHESIONS","87200863","CDM","510","RC","65860","HCPCS",,,"facility","inpatient",,,,"3429","3429",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG LASER EYE SEVER ADHESIONS","87200863","CDM","510","RC","65860","HCPCS",,,"facility","outpatient",,,,"3429","3429",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REP/REVISE ANTERIOR SEGMT","87200864","CDM","510","RC","66250","HCPCS",,,"facility","inpatient",,,,"15971","15971",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG REP/REVISE ANTERIOR SEGMT","87200864","CDM","510","RC","66250","HCPCS",,,"facility","outpatient",,,,"15971","15971",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CYCLOPHOTCOAG TRANSSCLERL BI","87200865","CDM","510","RC","66710","HCPCS",,,"facility","inpatient",,,"50","21124","21124",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CYCLOPHOTCOAG TRANSSCLERL BI","87200865","CDM","510","RC","66710","HCPCS",,,"facility","outpatient",,,"50","21124","21124",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG RVSN IRIS LASR EA SESSION BI","87200866","CDM","510","RC","66761","HCPCS",,,"facility","inpatient",,,"50","5870","5870",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG RVSN IRIS LASR EA SESSION BI","87200866","CDM","510","RC","66761","HCPCS",,,"facility","outpatient",,,"50","5870","5870",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DISCISSN 2ND MEM CAT LASR BI","87200867","CDM","510","RC","66821","HCPCS",,,"facility","inpatient",,,"50","5800","5800",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DISCISSN 2ND MEM CAT LASR BI","87200867","CDM","510","RC","66821","HCPCS",,,"facility","outpatient",,,"50","5800","5800",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INTRAVITREAL IJ DRUG BI","87200868","CDM","510","RC","67028","HCPCS",,,"facility","inpatient",,,"50","3939","3939",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INTRAVITREAL IJ DRUG BI","87200868","CDM","510","RC","67028","HCPCS",,,"facility","outpatient",,,"50","3939","3939",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG REPR RETINL DETACH AIR IJ BI","87200869","CDM","510","RC","67110","HCPCS",,,"facility","inpatient",,,"50","21616","21616",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG REPR RETINL DETACH AIR IJ BI","87200869","CDM","510","RC","67110","HCPCS",,,"facility","outpatient",,,"50","21616","21616",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PROPH RET DETACH CRYO/DIA BI","87200870","CDM","510","RC","67141","HCPCS",,,"facility","inpatient",,,"50","20835","20835",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PROPH RET DETACH CRYO/DIA BI","87200870","CDM","510","RC","67141","HCPCS",,,"facility","outpatient",,,"50","20835","20835",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PROPH RET DETCH PHOTOCOAG BI","87200871","CDM","510","RC","67145","HCPCS",,,"facility","inpatient",,,"50","7940","7940",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PROPH RET DETCH PHOTOCOAG BI","87200871","CDM","510","RC","67145","HCPCS",,,"facility","outpatient",,,"50","7940","7940",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DSTRCT RETNL LSN CRYO/DIA BI","87200872","CDM","510","RC","67208","HCPCS",,,"facility","inpatient",,,"50","20835","20835",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DSTRCT RETNL LSN CRYO/DIA BI","87200872","CDM","510","RC","67208","HCPCS",,,"facility","outpatient",,,"50","20835","20835",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG RET LES PHOTOCOAGULATION BI","87200873","CDM","510","RC","67210","HCPCS",,,"facility","inpatient",,,"50","8920","8920",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG RET LES PHOTOCOAGULATION BI","87200873","CDM","510","RC","67210","HCPCS",,,"facility","outpatient",,,"50","8920","8920",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DSTRCT RTNPTHY CRYO/DIATH","87200874","CDM","510","RC","67227","HCPCS",,,"facility","inpatient",,,,"4376","4376",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG DSTRCT RTNPTHY CRYO/DIATH","87200874","CDM","510","RC","67227","HCPCS",,,"facility","outpatient",,,,"4376","4376",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TX RTNPTHY PHOTOCOAGULATN BI","87200875","CDM","510","RC","67228","HCPCS",,,"facility","inpatient",,,"50","5956","5956",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TX RTNPTHY PHOTOCOAGULATN BI","87200875","CDM","510","RC","67228","HCPCS",,,"facility","outpatient",,,"50","5956","5956",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CHEMO DENERV EXTROC MUSC BI","87200876","CDM","510","RC","67345","HCPCS",,,"facility","inpatient",,,"50","4540","4540",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CHEMO DENERV EXTROC MUSC BI","87200876","CDM","510","RC","67345","HCPCS",,,"facility","outpatient",,,"50","4540","4540",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TENON'S CAPSULE INJECTION BI","87200878","CDM","510","RC","67515","HCPCS",,,"facility","inpatient",,,"50","4488","4488",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TENON'S CAPSULE INJECTION BI","87200878","CDM","510","RC","67515","HCPCS",,,"facility","outpatient",,,"50","4488","4488",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG EXCISION CHALAZION SNGL","87200879","CDM","510","RC","67800","HCPCS",,,"facility","inpatient",,,,"1367","1367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EXCISION CHALAZION SNGL","87200879","CDM","510","RC","67800","HCPCS",,,"facility","outpatient",,,,"1367","1367",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INCISIONAL BIOPSY EYELID SKIN & LID MARGIN BI","87200880","CDM","510","RC","67810","HCPCS",,,"facility","inpatient",,,"50","1443","1443",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INCISIONAL BIOPSY EYELID SKIN & LID MARGIN BI","87200880","CDM","510","RC","67810","HCPCS",,,"facility","outpatient",,,"50","1443","1443",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TRICH EPILATION FORCEPS BI","87200881","CDM","510","RC","67820","HCPCS",,,"facility","inpatient",,,"50","1514","1514",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TRICH EPILATION FORCEPS BI","87200881","CDM","510","RC","67820","HCPCS",,,"facility","outpatient",,,"50","1514","1514",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TRICH EPILATION OTHER BI","87200882","CDM","510","RC","67825","HCPCS",,,"facility","inpatient",,,"50","3506","3506",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG TRICH EPILATION OTHER BI","87200882","CDM","510","RC","67825","HCPCS",,,"facility","outpatient",,,"50","3506","3506",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INCISION CONJUNCTIVA BI","87200883","CDM","510","RC","68020","HCPCS",,,"facility","inpatient",,,"50","6668","6668",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INCISION CONJUNCTIVA BI","87200883","CDM","510","RC","68020","HCPCS",,,"facility","outpatient",,,"50","6668","6668",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY CONJUNCTIVA BI","87200884","CDM","510","RC","68100","HCPCS",,,"facility","inpatient",,,"50","15334","15334",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY CONJUNCTIVA BI","87200884","CDM","510","RC","68100","HCPCS",,,"facility","outpatient",,,"50","15334","15334",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG SUBCONJUNCTIVAL INJECTION BI","87200885","CDM","510","RC","68200","HCPCS",,,"facility","inpatient",,,"50","3015","3015",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG SUBCONJUNCTIVAL INJECTION BI","87200885","CDM","510","RC","68200","HCPCS",,,"facility","outpatient",,,"50","3015","3015",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INCIS/DRN LACRIMAL GLAND BI","87200886","CDM","510","RC","68400","HCPCS",,,"facility","inpatient",,,"50","10784","10784",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG INCIS/DRN LACRIMAL GLAND BI","87200886","CDM","510","RC","68400","HCPCS",,,"facility","outpatient",,,"50","10784","10784",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY OF LACRIMAL SAC BI","87200887","CDM","510","RC","68525","HCPCS",,,"facility","inpatient",,,"50","27870","27870",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG BIOPSY OF LACRIMAL SAC BI","87200887","CDM","510","RC","68525","HCPCS",,,"facility","outpatient",,,"50","27870","27870",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG LACR PUNCT CLOSUR EA PLUG BI","87200888","CDM","510","RC","68761","HCPCS",,,"facility","inpatient",,,"50","5952","5952",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG LACR PUNCT CLOSUR EA PLUG BI","87200888","CDM","510","RC","68761","HCPCS",,,"facility","outpatient",,,"50","5952","5952",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DIL TEAR DUCT OPENING BI","87200889","CDM","510","RC","68801","HCPCS",,,"facility","inpatient",,,"50","2654","2654",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG DIL TEAR DUCT OPENING BI","87200889","CDM","510","RC","68801","HCPCS",,,"facility","outpatient",,,"50","2654","2654",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PROBE NASOLACRIMAL DUCT BI","87200890","CDM","510","RC","68810","HCPCS",,,"facility","inpatient",,,"50","4558","4558",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PROBE NASOLACRIMAL DUCT BI","87200890","CDM","510","RC","68810","HCPCS",,,"facility","outpatient",,,"50","4558","4558",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG EDUC REMEDIATION 20-30","87200892","CDM",,,,,,,"facility","inpatient",,,,"259","259",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EDUC REMEDIATION 20-30","87200892","CDM",,,,,,,"facility","outpatient",,,,"259","259",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EDUC REMEDIATION 45-50","87200894","CDM",,,,,,,"facility","inpatient",,,,"213","213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG EDUC REMEDIATION 45-50","87200894","CDM",,,,,,,"facility","outpatient",,,,"213","213",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VISL FLD EXAM W I&R INT","87200907","CDM","510","RC","92082","HCPCS",,,"facility","inpatient",,,,"623","623",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VISL FLD EXAM W I&R INT","87200907","CDM","510","RC","92082","HCPCS",,,"facility","outpatient",,,,"623","623",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VISL FLD EXAM W I&R EXT","87200908","CDM","510","RC","92083","HCPCS",,,"facility","inpatient",,,,"576","576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG VISL FLD EXAM W I&R EXT","87200908","CDM","510","RC","92083","HCPCS",,,"facility","outpatient",,,,"576","576",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENETIC COUNSELING 30 MN","87200914","CDM","510","RC","96040","HCPCS",,,"facility","inpatient",,,,"494","494",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENETIC COUNSELING 30 MN","87200914","CDM","510","RC","96040","HCPCS",,,"facility","outpatient",,,,"494","494",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSULIN PUMP THER EDUC","87200923","CDM","942","RC","99078","HCPCS",,,"facility","inpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSULIN PUMP THER EDUC","87200923","CDM","942","RC","99078","HCPCS",,,"facility","outpatient",,,,"172","172",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MED NUTR TX COND CH EA15","87200927","CDM","942","RC","G0270","HCPCS",,,"facility","inpatient",,,,"72","72",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MED NUTR TX COND CH EA15","87200927","CDM","942","RC","G0270","HCPCS",,,"facility","outpatient",,,,"72","72",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MED NUTR TX GP COND EA30","87200928","CDM","942","RC","G0271","HCPCS",,,"facility","inpatient",,,,"251","251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG MED NUTR TX GP COND EA30","87200928","CDM","942","RC","G0271","HCPCS",,,"facility","outpatient",,,,"251","251",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PANCREAS ACQUISITON COMBO","87200929","CDM","812","RC",,,,,"facility","inpatient",,,,"183000","183000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PANCREAS ACQUISITON COMBO","87200929","CDM","812","RC",,,,,"facility","outpatient",,,,"183000","183000",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTERROGATION VAD IN PERSON","87200948","CDM","920","RC","93750","HCPCS",,,"facility","inpatient",,,,"312","312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INTERROGATION VAD IN PERSON","87200948","CDM","920","RC","93750","HCPCS",,,"facility","outpatient",,,,"312","312",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH CLINIC LEVEL 1","87200951","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","278","278",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 1","87200951","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","278","278",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 2","87200952","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","355","355",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 2","87200952","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","355","355",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 3","87200953","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","409","409",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 3","87200953","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","409","409",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 4","87200954","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","470","470",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 4","87200954","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","470","470",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 5","87200955","CDM","510","RC","G0463","HCPCS",,,"facility","inpatient",,,"95","540","540",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CLINIC LEVEL 5","87200955","CDM","510","RC","G0463","HCPCS",,,"facility","outpatient",,,"95","540","540",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH TELEHEALTH ORIGINATING SITE FEE","87200957","CDM","780","RC","Q3014","HCPCS",,,"facility","inpatient",,,,"87","87",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH TELEHEALTH ORIGINATING SITE FEE","87200957","CDM","780","RC","Q3014","HCPCS",,,"facility","outpatient",,,,"87","87",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH OPHTHALMIC EXAM NEW PT INTERMEDIATE","87200958","CDM","510","RC","92002","HCPCS",,,"facility","inpatient",,,"95","294","294",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OPHTHALMIC EXAM NEW PT INTERMEDIATE","87200958","CDM","510","RC","92002","HCPCS",,,"facility","outpatient",,,"95","294","294",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OPHTHALMIC EXAM NEW PT COMPREHENSIVE","87200959","CDM","510","RC","92004","HCPCS",,,"facility","inpatient",,,"95","341","341",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OPHTHALMIC EXAM NEW PT COMPREHENSIVE","87200959","CDM","510","RC","92004","HCPCS",,,"facility","outpatient",,,"95","339","339",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OPHTHALMIC EXAM EST PT INTERMEDIATE","87200960","CDM","510","RC","92012","HCPCS",,,"facility","inpatient",,,"95","296","296",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OPHTHALMIC EXAM EST PT INTERMEDIATE","87200960","CDM","510","RC","92012","HCPCS",,,"facility","outpatient",,,"95","296","296",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OPHTHALMIC EXAM EST PT COMPREHENSIVE","87200961","CDM","510","RC","92014","HCPCS",,,"facility","inpatient",,,"95","286","286",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH OPHTHALMIC EXAM EST PT COMPREHENSIVE","87200961","CDM","510","RC","92014","HCPCS",,,"facility","outpatient",,,"95","286","286",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH CCS ASSESS RN SPECIAL 30M","87200972","CDM",,,,,,,"facility","inpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH CCS ASSESS RN SPECIAL 30M","87200972","CDM",,,,,,,"facility","outpatient",,,,"108","108",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH CCS EVAL INTERVENTION SW 30M","87200973","CDM",,,,,,,"facility","inpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH CCS EVAL INTERVENTION SW 30M","87200973","CDM",,,,,,,"facility","outpatient",,,,"78","78",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH GENETIC COUNSELING 30 MN","87200988","CDM","510","RC","96040","HCPCS",,,"facility","inpatient",,,"95","494","494",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH GENETIC COUNSELING 30 MN","87200988","CDM","510","RC","96040","HCPCS",,,"facility","outpatient",,,"95","494","494",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG  ASSMT & CARE PLN PT COG IMP","87200989","CDM","510","RC","99483","HCPCS",,,"facility","inpatient",,,,"291","291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG  ASSMT & CARE PLN PT COG IMP","87200989","CDM","510","RC","99483","HCPCS",,,"facility","outpatient",,,,"291","291",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRAIN CANAL INJ W MEDS","87200990","CDM","510","RC","61026","HCPCS",,,"facility","inpatient",,,,"1765","1765",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BRAIN CANAL INJ W MEDS","87200990","CDM","510","RC","61026","HCPCS",,,"facility","outpatient",,,,"1765","1765",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 30MCG/.3ML PFIZER 1ST DOS","87200991","CDM","771","RC","0001A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 30MCG/.3ML PFIZER 1ST DOS","87200991","CDM","771","RC","0001A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 30MCG/.3ML PFIZ 2ND DOS","87200992","CDM","771","RC","0002A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 30MCG/.3ML PFIZ 2ND DOS","87200992","CDM","771","RC","0002A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 100MCG/.5ML MODRNA 1ST DOS","87200993","CDM","771","RC","0011A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 100MCG/.5ML MODRNA 1ST DOS","87200993","CDM","771","RC","0011A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 100MCG/.5ML MODRNA 2ND DOS","87200994","CDM","771","RC","0012A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 100MCG/.5ML MODRNA 2ND DOS","87200994","CDM","771","RC","0012A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 V PART/.5ML AZENECA 1ST DOS","87200995","CDM","771","RC","0021A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 V PART/.5ML AZENECA 1ST DOS","87200995","CDM","771","RC","0021A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 V PART/.5ML AZENECA 2ND DOS","87200996","CDM","771","RC","0022A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 V PART/.5ML AZENECA 2ND DOS","87200996","CDM","771","RC","0022A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION/POST ADMIN CASIRIVIMAB IMDEVIMAB","87200998","CDM","771","RC","M0243","HCPCS",,,"facility","inpatient",,,,"1309","1309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INFUSION/POST ADMIN CASIRIVIMAB IMDEVIMAB","87200998","CDM","771","RC","M0243","HCPCS",,,"facility","outpatient",,,,"1309","1309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 VAC AD26 .5ML JANSSEN","87200999","CDM","771","RC","0031A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 VAC AD26 .5ML JANSSEN","87200999","CDM","771","RC","0031A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 5MCG/.5ML NOVAVAX 1ST DOS","87201015","CDM","771","RC","0041A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 5MCG/.5ML NOVAVAX 1ST DOS","87201015","CDM","771","RC","0041A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 5MCG/.5ML NOVAVAX 2ND DOS","87201016","CDM","771","RC","0042A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 5MCG/.5ML NOVAVAX 2ND DOS","87201016","CDM","771","RC","0042A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SOTROVIMAB INFUSION","87201017","CDM","771","RC","M0247","HCPCS",,,"facility","inpatient",,,,"1402","1402",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SOTROVIMAB INFUSION","87201017","CDM","771","RC","M0247","HCPCS",,,"facility","outpatient",,,,"1402","1402",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 30MCG/0.3ML PFIZER 3RD DOSE","87201018","CDM","771","RC","0003A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 30MCG/0.3ML PFIZER 3RD DOSE","87201018","CDM","771","RC","0003A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 100MCG/.5ML MODRNA 3RD DOS","87201019","CDM","771","RC","0013A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 100MCG/.5ML MODRNA 3RD DOS","87201019","CDM","771","RC","0013A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 30MCG/.3ML PFIZER BSTR","87201020","CDM","771","RC","0004A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 30MCG/.3ML PFIZER BSTR","87201020","CDM","771","RC","0004A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50MCG/0.25ML MODERNA BST","87201021","CDM","771","RC","0064A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50MCG/0.25ML MODERNA BST","87201021","CDM","771","RC","0064A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 10MCG TRS-SUCR  PFIZER 1ST","87201022","CDM","771","RC","0071A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 10MCG TRS-SUCR  PFIZER 1ST","87201022","CDM","771","RC","0071A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 10MCG TRS-SUCR PFIZER 2ND","87201023","CDM","771","RC","0072A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 10MCG TRS-SUCR PFIZER 2ND","87201023","CDM","771","RC","0072A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 30MCG TRS-SUCR PFIZER 1ST","87201024","CDM","771","RC","0051A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 30MCG TRS-SUCR PFIZER 1ST","87201024","CDM","771","RC","0051A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 30MCG TRS-SUCR 2 PFIZER 2ND","87201025","CDM","771","RC","0052A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 30MCG TRS-SUCR 2 PFIZER 2ND","87201025","CDM","771","RC","0052A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 30MCG TRS-SUCR 3 PFIZER BSTR","87201026","CDM","771","RC","0054A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 30MCG TRS-SUCR 3 PFIZER BSTR","87201026","CDM","771","RC","0054A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 30MCG TRS-SUCR 3 PFIZER 3RD","87201027","CDM","771","RC","0053A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 30MCG TRS-SUCR 3 PFIZER 3RD","87201027","CDM","771","RC","0053A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIXAGEV AND CILGAV INJ","87201032","CDM","771","RC","M0220","HCPCS",,,"facility","inpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TIXAGEV AND CILGAV INJ","87201032","CDM","771","RC","M0220","HCPCS",,,"facility","outpatient",,,,"457","457",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 10MCG TRS-SUCR  PFIZER 3RD","87201033","CDM","771","RC","0073A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 10MCG TRS-SUCR  PFIZER 3RD","87201033","CDM","771","RC","0073A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 VAC AD26 .5ML JANSSEN BSTR","87201034","CDM","771","RC","0034A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 VAC AD26 .5ML JANSSEN BSTR","87201034","CDM","771","RC","0034A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 3MCG TRS-SUCR 1ST DOS","87201035","CDM","771","RC","0081A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 3MCG TRS-SUCR 1ST DOS","87201035","CDM","771","RC","0081A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 3MCG TRS-SUCR 2ND DOS","87201036","CDM","771","RC","0082A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 3MCG TRS-SUCR 2ND DOS","87201036","CDM","771","RC","0082A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BEBTELOVIMAB INJECTION","87201037","CDM","771","RC","M0222","HCPCS",,,"facility","inpatient",,,,"1409","1409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BEBTELOVIMAB INJECTION","87201037","CDM","771","RC","M0222","HCPCS",,,"facility","outpatient",,,,"1409","1409",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50MCG/0.5ML MODERNA BST","87201038","CDM","771","RC","0094A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50MCG/0.5ML MODERNA BST","87201038","CDM","771","RC","0094A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 10MCG TRS-SUCR PFIZER BSTR","87201039","CDM","771","RC","0074A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 10MCG TRS-SUCR PFIZER BSTR","87201039","CDM","771","RC","0074A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 25MCG/0.25ML MODERNA PED 1ST","87201040","CDM","771","RC","0111A","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 25MCG/0.25ML MODERNA PED 1ST","87201040","CDM","771","RC","0111A","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 25MCG/0.25ML MODERNA PED 2ND","87201041","CDM","771","RC","0112A","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 25MCG/0.25ML MODERNA PED 2ND","87201041","CDM","771","RC","0112A","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 3MCG TRS-SUCR 3RD DOS","87201042","CDM","771","RC","0083A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 3MCG TRS-SUCR 3RD DOS","87201042","CDM","771","RC","0083A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50 MCG/.5 ML1ST","87201043","CDM","771","RC","0091A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50 MCG/.5 ML1ST","87201043","CDM","771","RC","0091A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50 MCG/.5 ML2ND","87201044","CDM","771","RC","0092A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50 MCG/.5 ML2ND","87201044","CDM","771","RC","0092A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50 MCG/.5 ML3RD","87201045","CDM","771","RC","0093A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 50 MCG/.5 ML3RD","87201045","CDM","771","RC","0093A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 25MCG/0.25ML3RD","87201046","CDM","771","RC","0113A","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 25MCG/0.25ML3RD","87201046","CDM","771","RC","0113A","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM TOCILIZU COVID-19 1ST","87201047","CDM","771","RC","M0249","HCPCS",,,"facility","inpatient",,,,"1162","1162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM TOCILIZU COVID-19 1ST","87201047","CDM","771","RC","M0249","HCPCS",,,"facility","outpatient",,,,"1162","1162",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM TOCILIZU COVID-19 2ND","87201048","CDM","771","RC","M0250","HCPCS",,,"facility","inpatient",,,,"1263","1263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM TOCILIZU COVID-19 2ND","87201048","CDM","771","RC","M0250","HCPCS",,,"facility","outpatient",,,,"1263","1263",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 BVLNT 30MCG TRS-SUC PFIZER ADDL","87201049","CDM","771","RC","0124A","HCPCS",,,"facility","inpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 BVLNT 30MCG TRS-SUC PFIZER ADDL","87201049","CDM","771","RC","0124A","HCPCS",,,"facility","outpatient",,,,"121","121",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCOV2 BIVALENT 50MCG/0.5ML MODERNA ADDL","87201050","CDM","771","RC","0134A","HCPCS",,,"facility","inpatient",,,,"100","100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCOV2 BIVALENT 50MCG/0.5ML MODERNA ADDL","87201050","CDM","771","RC","0134A","HCPCS",,,"facility","outpatient",,,,"100","100",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 BVLNT 10MCG TRS-SUCR PFIZER ADD","87201051","CDM","771","RC","0154A","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 BVLNT 10MCG TRS-SUCR PFIZER ADD","87201051","CDM","771","RC","0154A","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCOV2 BVLNT 25MCG/.25ML MODERNA PED ADDL","87201052","CDM","771","RC","0144A","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCOV2 BVLNT 25MCG/.25ML MODERNA PED ADDL","87201052","CDM","771","RC","0144A","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 5MCG/.5ML NOVAVAX BSTR","87201053","CDM","771","RC","0044A","HCPCS",,,"facility","inpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 5MCG/.5ML NOVAVAX BSTR","87201053","CDM","771","RC","0044A","HCPCS",,,"facility","outpatient",,,,"65","65",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 10MCG/0.2ML MODERNA PED ADDL","87201054","CDM","771","RC","0164A","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCOV2 10MCG/0.2ML MODERNA PED ADDL","87201054","CDM","771","RC","0164A","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 BVL 3MCG/0.2ML 3RD","87201055","CDM","771","RC","0173A","HCPCS",,,"facility","inpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 BVL 3MCG/0.2ML 3RD","87201055","CDM","771","RC","0173A","HCPCS",,,"facility","outpatient",,,,"79","79",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCV2 BVL 30MCG/.2ML ADDL","87201056","CDM","771","RC","0174A","HCPCS",,,"facility","inpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCV2 BVL 30MCG/.2ML ADDL","87201056","CDM","771","RC","0174A","HCPCS",,,"facility","outpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 BVLNT 30MCG TRS-SUC PFIZER 1ST","87201057","CDM","771","RC","0121A","HCPCS",,,"facility","inpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADM SARSCV2 BVLNT 30MCG TRS-SUC PFIZER 1ST","87201057","CDM","771","RC","0121A","HCPCS",,,"facility","outpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCOV2 BVLNT 25MCG/.25ML MODERNA PED 1ST","87201058","CDM","771","RC","0141A","HCPCS",,,"facility","inpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCOV2 BVLNT 25MCG/.25ML MODERNA PED 1ST","87201058","CDM","771","RC","0141A","HCPCS",,,"facility","outpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCOV2 BVLNT 25MCG/.25ML MODERNA PED 2ND","87201059","CDM","771","RC","0142A","HCPCS",,,"facility","inpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ADM SARSCOV2 BVLNT 25MCG/.25ML MODERNA PED 2ND","87201059","CDM","771","RC","0142A","HCPCS",,,"facility","outpatient",,,,"80","80",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPTR OPHTH DX IMG POST SG LT","87201074","CDM","510","RC","92134","HCPCS",,,"facility","inpatient",,,"LT","274","274",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CPTR OPHTH DX IMG POST SG LT","87201074","CDM","510","RC","92134","HCPCS",,,"facility","outpatient",,,"LT","274","274",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CPTR OPHTH DX IMG POST SG RT","87201075","CDM","510","RC","92134","HCPCS",,,"facility","inpatient",,,"RT","274","274",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CPTR OPHTH DX IMG POST SG RT","87201075","CDM","510","RC","92134","HCPCS",,,"facility","outpatient",,,"RT","274","274",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CMPTR OPHTH DX IM ANT SEG LT","87201076","CDM","510","RC","92132","HCPCS",,,"facility","inpatient",,,"LT","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CMPTR OPHTH DX IM ANT SEG LT","87201076","CDM","510","RC","92132","HCPCS",,,"facility","outpatient",,,"LT","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CMPTR OPHTH DX IM ANT SEG RT","87201077","CDM","510","RC","92132","HCPCS",,,"facility","inpatient",,,"RT","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CMPTR OPHTH DX IM ANT SEG RT","87201077","CDM","510","RC","92132","HCPCS",,,"facility","outpatient",,,"RT","211","211",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG IMM ADMN SARSCOV2 VACCINE 1ST/ONLY COMPNT","87201079","CDM","771","RC","90480","HCPCS",,,"facility","inpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG IMM ADMN SARSCOV2 VACCINE 1ST/ONLY COMPNT","87201079","CDM","771","RC","90480","HCPCS",,,"facility","outpatient",,,,"101","101",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PEMIVIBART INFUSION","87201084","CDM","771","RC","M0224","HCPCS",,,"facility","inpatient",,,,"1252","1252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PEMIVIBART INFUSION","87201084","CDM","771","RC","M0224","HCPCS",,,"facility","outpatient",,,,"1252","1252",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENETIC COUNSELING SVC EA 30","87201088","CDM","510","RC","96041","HCPCS",,,"facility","inpatient",,,,"519","519",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GENETIC COUNSELING SVC EA 30","87201088","CDM","510","RC","96041","HCPCS",,,"facility","outpatient",,,,"519","519",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TH GENETIC COUNSELING SVC EA 30","87201089","CDM","510","RC","96041","HCPCS",,,"facility","inpatient",,,"95","519","519",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG TH GENETIC COUNSELING SVC EA 30","87201089","CDM","510","RC","96041","HCPCS",,,"facility","outpatient",,,"95","519","519",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"HCHG CPTRZ OPH IMG PST SG RTA OCT BILAT","87201091","CDM","510","RC","92137","HCPCS",,,"facility","inpatient",,,,"357","357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPTRZ OPH IMG PST SG RTA OCT BILAT","87201091","CDM","510","RC","92137","HCPCS",,,"facility","outpatient",,,,"357","357",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CPTRZ OPH IMG PST SG RTA OCT LT","87201092","CDM","510","RC","92137","HCPCS",,,"facility","inpatient",,,"LT","420","420",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CPTRZ OPH IMG PST SG RTA OCT LT","87201092","CDM","510","RC","92137","HCPCS",,,"facility","outpatient",,,"LT","420","420",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
"HCHG CPTRZ OPH IMG PST SG RTA OCT RT","87201093","CDM","510","RC","92137","HCPCS",,,"facility","inpatient",,,"RT","420","420",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CPTRZ OPH IMG PST SG RTA OCT RT","87201093","CDM","510","RC","92137","HCPCS",,,"facility","outpatient",,,"RT","420","420",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body)"
"HCHG CHW SUN EDUCATION IND EA 30 MIN","87201095","CDM","942","RC","98960","HCPCS",,,"facility","inpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHW SUN EDUCATION IND EA 30 MIN","87201095","CDM","942","RC","98960","HCPCS",,,"facility","outpatient",,,,"223","223",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SENSORIMOTOR EXAMINATION","87201100","CDM","510","RC","92060","HCPCS",,,"facility","inpatient",,,,"232","232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG SENSORIMOTOR EXAMINATION","87201100","CDM","510","RC","92060","HCPCS",,,"facility","outpatient",,,,"232","232",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPHAGEAL MOTILITY","87205001","CDM","750","RC","91010","HCPCS",,,"facility","inpatient",,,,"5960","5960",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPHAGEAL MOTILITY","87205001","CDM","750","RC","91010","HCPCS",,,"facility","outpatient",,,,"5960","5960",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTRIC MOTILITY","87205002","CDM","750","RC","91020","HCPCS",,,"facility","inpatient",,,,"3981","3981",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GASTRIC MOTILITY","87205002","CDM","750","RC","91020","HCPCS",,,"facility","outpatient",,,,"3981","3981",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPHAGUS ACID PERFUSION TEST","87205003","CDM","750","RC","91030","HCPCS",,,"facility","inpatient",,,,"727","727",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPHAGUS ACID PERFUSION TEST","87205003","CDM","750","RC","91030","HCPCS",,,"facility","outpatient",,,,"727","727",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PH ESOPHAGUS NASAL CATHETER ELECTRODE","87205004","CDM","750","RC","91034","HCPCS",,,"facility","inpatient",,,,"3840","3840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PH ESOPHAGUS NASAL CATHETER ELECTRODE","87205004","CDM","750","RC","91034","HCPCS",,,"facility","outpatient",,,,"3840","3840",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERTION PH CAPSULE GERD MUCOSAL","87205005","CDM","750","RC","91035","HCPCS",,,"facility","inpatient",,,,"4849","4849",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INSERTION PH CAPSULE GERD MUCOSAL","87205005","CDM","750","RC","91035","HCPCS",,,"facility","outpatient",,,,"4849","4849",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPHAGEAL BALLOON DISTENSION","87205008","CDM","750","RC","91040","HCPCS",,,"facility","inpatient",,,,"1236","1236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ESOPHAGEAL BALLOON DISTENSION","87205008","CDM","750","RC","91040","HCPCS",,,"facility","outpatient",,,,"1236","1236",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BREATH HYDROGEN METHANE TEST","87205010","CDM","750","RC","91065","HCPCS",,,"facility","inpatient",,,,"717","717",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG BREATH HYDROGEN METHANE TEST","87205010","CDM","750","RC","91065","HCPCS",,,"facility","outpatient",,,,"717","717",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM","87205013","CDM","750","RC","91110","HCPCS",,,"facility","inpatient",,,,"6187","6187",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM","87205013","CDM","750","RC","91110","HCPCS",,,"facility","outpatient",,,,"6187","6187",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANORECTAL MANOMETRY","87205014","CDM","510","RC","91122","HCPCS",,,"facility","inpatient",,,,"3133","3133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ANORECTAL MANOMETRY","87205014","CDM","510","RC","91122","HCPCS",,,"facility","outpatient",,,,"3133","3133",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELECTROGASTROGRAPHY DIAGNOSTIC","87205015","CDM","750","RC","91132","HCPCS",,,"facility","inpatient",,,,"2577","2577",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG ELECTROGASTROGRAPHY DIAGNOSTIC","87205015","CDM","750","RC","91132","HCPCS",,,"facility","outpatient",,,,"2577","2577",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CMPTR OPHTH DX IM ANT SEG BILAT","87205024","CDM","510","RC","92132","HCPCS",,,"facility","inpatient",,,,"211","211",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CMPTR OPHTH DX IM ANT SEG BILAT","87205024","CDM","510","RC","92132","HCPCS",,,"facility","outpatient",,,,"211","211",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRIM NONDYSTRPHIC NAIL","87205031","CDM","510","RC","11719","HCPCS",,,"facility","inpatient",,,,"319","319",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG TRIM NONDYSTRPHIC NAIL","87205031","CDM","510","RC","11719","HCPCS",,,"facility","outpatient",,,,"319","319",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG INJS ANES/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL","87205041","CDM","510","RC","64483","HCPCS",,,"facility","outpatient",,,,"4901","4901",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CHEMODNRV MUSC-MUSC INNERVATED FACIAL NRV BI","87205055","CDM","510","RC","64612","HCPCS",,,"facility","inpatient",,,"50","1792","1792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG CHEMODNRV MUSC-MUSC INNERVATED FACIAL NRV BI","87205055","CDM","510","RC","64612","HCPCS",,,"facility","outpatient",,,"50","1792","1792",,,,,,,,,,,,,"Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"HCHG PARACENTSIS ABD NO IM","87205079","CDM","510","RC","49082","HCPCS",,,"facility","inpatient",,,,"3084","3084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG PARACENTSIS ABD NO IM","87205079","CDM","510","RC","49082","HCPCS",,,"facility","outpatient",,,,"3084","3084",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HI RES GASTRIC EP MAPPING","87205097","CDM","750","RC","0868T","HCPCS",,,"facility","inpatient",,,,"3309","3309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG HI RES GASTRIC EP MAPPING","87205097","CDM","750","RC","0868T","HCPCS",,,"facility","outpatient",,,,"3309","3309",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC CUSTOMETROGRAM W/UP","87300000","CDM","510","RC","51727","HCPCS",,,"facility","inpatient",,,,"2038","2038",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC CUSTOMETROGRAM W/UP","87300000","CDM","510","RC","51727","HCPCS",,,"facility","outpatient",,,,"2038","2038",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC CYYSTOMETROGRAM W/VP","87300001","CDM","510","RC","51728","HCPCS",,,"facility","inpatient",,,,"2652","2652",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC CYYSTOMETROGRAM W/VP","87300001","CDM","510","RC","51728","HCPCS",,,"facility","outpatient",,,,"2652","2652",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC CYSTOMETROGRAM W/VP&UP","87300002","CDM","510","RC","51729","HCPCS",,,"facility","inpatient",,,,"3125","3125",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG CLINIC CYSTOMETROGRAM W/VP&UP","87300002","CDM","510","RC","51729","HCPCS",,,"facility","outpatient",,,,"3125","3125",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL HOSPITAL CARE LOW","88000001","CDM","987","RC","99221","HCPCS",,,"facility","inpatient",,,,"385","385",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL HOSPITAL CARE LOW","88000001","CDM","987","RC","99221","HCPCS",,,"facility","outpatient",,,,"385","385",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL HOSPITAL CARE MED","88000002","CDM","987","RC","99222","HCPCS",,,"facility","inpatient",,,,"520","520",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL HOSPITAL CARE MED","88000002","CDM","987","RC","99222","HCPCS",,,"facility","outpatient",,,,"520","520",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL HOSPITAL CARE HIGH","88000003","CDM","987","RC","99223","HCPCS",,,"facility","inpatient",,,,"771","771",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL HOSPITAL CARE HIGH","88000003","CDM","987","RC","99223","HCPCS",,,"facility","outpatient",,,,"771","771",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT HOSPITAL CARE LOW","88000004","CDM","987","RC","99231","HCPCS",,,"facility","inpatient",,,,"149","149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT HOSPITAL CARE LOW","88000004","CDM","987","RC","99231","HCPCS",,,"facility","outpatient",,,,"149","149",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT HOSPITAL CARE MED","88000005","CDM","987","RC","99232","HCPCS",,,"facility","inpatient",,,,"276","276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT HOSPITAL CARE MED","88000005","CDM","987","RC","99232","HCPCS",,,"facility","outpatient",,,,"276","276",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT HOSPITAL CARE HIGH","88000006","CDM","987","RC","99233","HCPCS",,,"facility","inpatient",,,,"399","399",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT HOSPITAL CARE HIGH","88000006","CDM","987","RC","99233","HCPCS",,,"facility","outpatient",,,,"399","399",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC HOSPITAL DISCHARGE SERVICES LOW","88000007","CDM","987","RC","99238","HCPCS",,,"facility","inpatient",,,,"282","282",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC HOSPITAL DISCHARGE SERVICES LOW","88000007","CDM","987","RC","99238","HCPCS",,,"facility","outpatient",,,,"282","282",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC HOSPITAL DISCHARGE SERVICES HIGH","88000008","CDM","987","RC","99239","HCPCS",,,"facility","inpatient",,,,"413","413",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC HOSPITAL DISCHARGE SERVICES HIGH","88000008","CDM","987","RC","99239","HCPCS",,,"facility","outpatient",,,,"413","413",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL OBSERVATION CARE LOW","88000009","CDM","987","RC","99218","HCPCS",,,"facility","inpatient",,,,"378","378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL OBSERVATION CARE LOW","88000009","CDM","987","RC","99218","HCPCS",,,"facility","outpatient",,,,"378","378",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL OBSERVATION CARE MOD","88000010","CDM","987","RC","99219","HCPCS",,,"facility","inpatient",,,,"518","518",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL OBSERVATION CARE MOD","88000010","CDM","987","RC","99219","HCPCS",,,"facility","outpatient",,,,"518","518",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL OBSERVATION CARE HIGH","88000011","CDM","987","RC","99220","HCPCS",,,"facility","inpatient",,,,"705","705",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC INITIAL OBSERVATION CARE HIGH","88000011","CDM","987","RC","99220","HCPCS",,,"facility","outpatient",,,,"705","705",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT OBSERVATION CARE LOW","88000012","CDM","987","RC","99224","HCPCS",,,"facility","inpatient",,,,"150","150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT OBSERVATION CARE LOW","88000012","CDM","987","RC","99224","HCPCS",,,"facility","outpatient",,,,"150","150",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT OBSERVATION CARE MOD","88000013","CDM","987","RC","99225","HCPCS",,,"facility","inpatient",,,,"278","278",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT OBSERVATION CARE MOD","88000013","CDM","987","RC","99225","HCPCS",,,"facility","outpatient",,,,"278","278",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT OBSERVATION CARE HIGH","88000014","CDM","987","RC","99226","HCPCS",,,"facility","inpatient",,,,"400","400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC SUBSEQUENT OBSERVATION CARE HIGH","88000014","CDM","987","RC","99226","HCPCS",,,"facility","outpatient",,,,"400","400",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC OBSERVATION CARE DISCHARGE SERVICES","88000015","CDM","987","RC","99217","HCPCS",,,"facility","inpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC OBSERVATION CARE DISCHARGE SERVICES","88000015","CDM","987","RC","99217","HCPCS",,,"facility","outpatient",,,,"280","280",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC OBS OR INPT CARE SVCS INCL ADM/DSCHRG LOW","88000016","CDM","987","RC","99234","HCPCS",,,"facility","inpatient",,,,"507","507",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC OBS OR INPT CARE SVCS INCL ADM/DSCHRG LOW","88000016","CDM","987","RC","99234","HCPCS",,,"facility","outpatient",,,,"507","507",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC OBS OR INPT CARE SVCS INCL ADM/DSCHRG MOD","88000017","CDM","987","RC","99235","HCPCS",,,"facility","inpatient",,,,"644","644",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC OBS OR INPT CARE SVCS INCL ADM/DSCHRG MOD","88000017","CDM","987","RC","99235","HCPCS",,,"facility","outpatient",,,,"644","644",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC OBS OR INPT CARE SVCS INCL ADM/DSCHRG HIGH","88000018","CDM","987","RC","99236","HCPCS",,,"facility","inpatient",,,,"828","828",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC OBS OR INPT CARE SVCS INCL ADM/DSCHRG HIGH","88000018","CDM","987","RC","99236","HCPCS",,,"facility","outpatient",,,,"828","828",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC CC 1ST 30-74 MIN","88000019","CDM","987","RC","99291","HCPCS",,,"facility","inpatient",,,,"876","876",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC CC 1ST 30-74 MIN","88000019","CDM","987","RC","99291","HCPCS",,,"facility","outpatient",,,,"876","876",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC CC EA ADD 30 MIN","88000020","CDM","987","RC","99292","HCPCS",,,"facility","inpatient",,,,"440","440",,,,,,,,,,,,,"Gross Charge Type: Standard"
"HCHG APC CC EA ADD 30 MIN","88000020","CDM","987","RC","99292","HCPCS",,,"facility","outpatient",,,,"440","440",,,,,,,,,,,,,"Gross Charge Type: Standard"
"Fna bx w/us gdn 1st les","10005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3835",,,,,,,"fee schedule","3304","4005",
"Fna bx w/us gdn 1st les","10005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3304",,,,,,,"fee schedule","3304","4005",
"Fna bx w/us gdn 1st les","10005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4005",,,,,,,"fee schedule","3304","4005",
"Fna bx w/us gdn 1st les","10005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3536",,,,,,,"fee schedule","3304","4005",
"Fna bx w/us gdn 1st les","10005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4005",,,,,,,"fee schedule","3304","4005",
"Fna bx w/us gdn 1st les","10005","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3652",,,,,,,"fee schedule","3304","4005",
"Fna bx w/us gdn 1st les","10005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3835",,,,,,,"fee schedule","3304","4005",
"Remove pilonidal cyst simple","11770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16631",,,,,,,"fee schedule","14332","17372",
"Remove pilonidal cyst simple","11770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17372",,,,,,,"fee schedule","14332","17372",
"Remove pilonidal cyst simple","11770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17372",,,,,,,"fee schedule","14332","17372",
"Remove pilonidal cyst simple","11770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15331",,,,,,,"fee schedule","14332","17372",
"Remove pilonidal cyst simple","11770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14332",,,,,,,"fee schedule","14332","17372",
"Remove pilonidal cyst simple","11770","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15841",,,,,,,"fee schedule","14332","17372",
"Remove pilonidal cyst simple","11770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16631",,,,,,,"fee schedule","14332","17372",
"Remove pilonidal cyst exten","11771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16033",,,,,,,"fee schedule","13815","16746",
"Remove pilonidal cyst exten","11771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14777",,,,,,,"fee schedule","13815","16746",
"Remove pilonidal cyst exten","11771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16746",,,,,,,"fee schedule","13815","16746",
"Remove pilonidal cyst exten","11771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16746",,,,,,,"fee schedule","13815","16746",
"Remove pilonidal cyst exten","11771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","13815",,,,,,,"fee schedule","13815","16746",
"Remove pilonidal cyst exten","11771","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15269",,,,,,,"fee schedule","13815","16746",
"Remove pilonidal cyst exten","11771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16033",,,,,,,"fee schedule","13815","16746",
"Remove pilonidal cyst compl","11772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","17891",,,,,,,"fee schedule","15418","18687",
"Remove pilonidal cyst compl","11772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","15418",,,,,,,"fee schedule","15418","18687",
"Remove pilonidal cyst compl","11772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16491",,,,,,,"fee schedule","15418","18687",
"Remove pilonidal cyst compl","11772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18687",,,,,,,"fee schedule","15418","18687",
"Remove pilonidal cyst compl","11772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18687",,,,,,,"fee schedule","15418","18687",
"Remove pilonidal cyst compl","11772","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17042",,,,,,,"fee schedule","15418","18687",
"Remove pilonidal cyst compl","11772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","17891",,,,,,,"fee schedule","15418","18687",
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","10851",,,,,,,"fee schedule","9350","11334",
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10000",,,,,,,"fee schedule","9350","11334",
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11334",,,,,,,"fee schedule","9350","11334",
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11334",,,,,,,"fee schedule","9350","11334",
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9350",,,,,,,"fee schedule","9350","11334",
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10333",,,,,,,"fee schedule","9350","11334",
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","10851",,,,,,,"fee schedule","9350","11334",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5073",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4634",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5103",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3845",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4782",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4507",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5103",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4343",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4728",,,,,,,"fee schedule","3845","5103",
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4634",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5073",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4634",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5103",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4782",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3845",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4343",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4507",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5103",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4728",,,,,,,"fee schedule","3845","5103",
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4634",,,,,,,"fee schedule","3845","5103",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7252",,,,,,,"fee schedule","6442","18663",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11516",,,,,,,"fee schedule","6442","18663",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","18663",,,,,,,"fee schedule","6442","18663",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12870",,,,,,,"fee schedule","6442","18663",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6442",,,,,,,"fee schedule","6442","18663",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12870",,,,,,,"fee schedule","6442","18663",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12870",,,,,,,"fee schedule","6442","18663",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11092",,,,,,,"fee schedule","6442","18663",
"Grfg autol soft tiss dir exc","15769","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","18663",,,,,,,"fee schedule","6442","18663",
"Derma-fat-fascia graft","15770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12870",,,,,,,"fee schedule","6442","12870",
"Derma-fat-fascia graft","15770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6442",,,,,,,"fee schedule","6442","12870",
"Derma-fat-fascia graft","15770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12870",,,,,,,"fee schedule","6442","12870",
"Derma-fat-fascia graft","15770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12870",,,,,,,"fee schedule","6442","12870",
"Derma-fat-fascia graft","15770","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11092",,,,,,,"fee schedule","6442","12870",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7252",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","18663",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11516",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6442",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12870",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12870",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12870",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11092",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo 50 cc/<","15771","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","18663",,,,,,,"fee schedule","6442","18663",
"Grfg autol fat lipo ea addl","15772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6477",,,,,,,"fee schedule","5582","6477",
"Grfg autol fat lipo ea addl","15772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6477",,,,,,,"fee schedule","5582","6477",
"Grfg autol fat lipo ea addl","15772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6477",,,,,,,"fee schedule","5582","6477",
"Grfg autol fat lipo ea addl","15772","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6442",,,,,,,"fee schedule","5582","6477",
"Grfg autol fat lipo ea addl","15772","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5582",,,,,,,"fee schedule","5582","6477",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4390",,,,,,,"fee schedule","2765","9331",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","9331",,,,,,,"fee schedule","2765","9331",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2765",,,,,,,"fee schedule","2765","9331",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8412",,,,,,,"fee schedule","2765","9331",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8412",,,,,,,"fee schedule","2765","9331",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8412",,,,,,,"fee schedule","2765","9331",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3544",,,,,,,"fee schedule","2765","9331",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7249",,,,,,,"fee schedule","2765","9331",
"Grfg autol fat lipo 25 cc/<","15773","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","9331",,,,,,,"fee schedule","2765","9331",
"Gfrg autol fat lipo ea addl","15774","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4206",,,,,,,"fee schedule","3544","4206",
"Gfrg autol fat lipo ea addl","15774","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4206",,,,,,,"fee schedule","3544","4206",
"Gfrg autol fat lipo ea addl","15774","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4206",,,,,,,"fee schedule","3544","4206",
"Gfrg autol fat lipo ea addl","15774","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3544",,,,,,,"fee schedule","3544","4206",
"Gfrg autol fat lipo ea addl","15774","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3625",,,,,,,"fee schedule","3544","4206",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5904",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3845",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5073",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5103",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5533",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4507",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5103",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6089",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6020",,,,,,,"fee schedule","3845","6089",
"Revision of upper eyelid","15823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5904",,,,,,,"fee schedule","3845","6089",
"Exc Skin Abd","15830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15050",,,,,,,"fee schedule","10228","15050",
"Exc Skin Abd","15830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","14961",,,,,,,"fee schedule","10228","15050",
"Exc Skin Abd","15830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","11338",,,,,,,"fee schedule","10228","15050",
"Exc Skin Abd","15830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10228",,,,,,,"fee schedule","10228","15050",
"Exc Skin Abd","15830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15050",,,,,,,"fee schedule","10228","15050",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6438",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2943",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6642",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2230",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3056",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3056",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2699",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6034",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6438",,,,,,,"fee schedule","2230","6642",
"Exc Skin Abd Add-on","15847","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6564",,,,,,,"fee schedule","2230","6642",
"Suction lipectomy trunk","15877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","6286",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy trunk","15877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8239",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy trunk","15877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","8296",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy trunk","15877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6089",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy trunk","15877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8239",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy lwr extrem","15879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8239",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy lwr extrem","15879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","6286",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy lwr extrem","15879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","8296",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy lwr extrem","15879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6089",,,,,,,"fee schedule","6089","8296",
"Suction lipectomy lwr extrem","15879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8239",,,,,,,"fee schedule","6089","8296",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","901",,,,,,,"fee schedule","727","1006",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","727",,,,,,,"fee schedule","727","1006",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","888",,,,,,,"fee schedule","727","1006",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","959",,,,,,,"fee schedule","727","1006",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1006",,,,,,,"fee schedule","727","1006",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","795",,,,,,,"fee schedule","727","1006",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1006",,,,,,,"fee schedule","727","1006",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","913",,,,,,,"fee schedule","727","1006",
"Destruct premalg lesion","17000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","901",,,,,,,"fee schedule","727","1006",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","901",,,,,,,"fee schedule","774","1022",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","774",,,,,,,"fee schedule","774","1022",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","901",,,,,,,"fee schedule","774","1022",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1022",,,,,,,"fee schedule","774","1022",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","795",,,,,,,"fee schedule","774","1022",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1021",,,,,,,"fee schedule","774","1022",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1021",,,,,,,"fee schedule","774","1022",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","913",,,,,,,"fee schedule","774","1022",
"Destroy premal lesions 15/>","17004","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","901",,,,,,,"fee schedule","774","1022",
"Bx breast 1st lesion strtctc","19081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8196",,,,,,,"fee schedule","7062","8561",
"Bx breast 1st lesion strtctc","19081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8561",,,,,,,"fee schedule","7062","8561",
"Bx breast 1st lesion strtctc","19081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8561",,,,,,,"fee schedule","7062","8561",
"Bx breast 1st lesion strtctc","19081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7554",,,,,,,"fee schedule","7062","8561",
"Bx breast 1st lesion strtctc","19081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7062",,,,,,,"fee schedule","7062","8561",
"Bx breast 1st lesion strtctc","19081","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7807",,,,,,,"fee schedule","7062","8561",
"Bx breast 1st lesion strtctc","19081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8196",,,,,,,"fee schedule","7062","8561",
"Bx breast 1st lesion us imag","19083","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5292",,,,,,,"fee schedule","4560","5528",
"Bx breast 1st lesion us imag","19083","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4880",,,,,,,"fee schedule","4560","5528",
"Bx breast 1st lesion us imag","19083","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5528",,,,,,,"fee schedule","4560","5528",
"Bx breast 1st lesion us imag","19083","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5528",,,,,,,"fee schedule","4560","5528",
"Bx breast 1st lesion us imag","19083","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4560",,,,,,,"fee schedule","4560","5528",
"Bx breast 1st lesion us imag","19083","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5041",,,,,,,"fee schedule","4560","5528",
"Bx breast 1st lesion us imag","19083","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5292",,,,,,,"fee schedule","4560","5528",
"Bx breast 1st lesion mr imag","19085","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8959",,,,,,,"fee schedule","7721","9357",
"Bx breast 1st lesion mr imag","19085","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8257",,,,,,,"fee schedule","7721","9357",
"Bx breast 1st lesion mr imag","19085","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7721",,,,,,,"fee schedule","7721","9357",
"Bx breast 1st lesion mr imag","19085","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9357",,,,,,,"fee schedule","7721","9357",
"Bx breast 1st lesion mr imag","19085","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9357",,,,,,,"fee schedule","7721","9357",
"Bx breast 1st lesion mr imag","19085","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8534",,,,,,,"fee schedule","7721","9357",
"Bx breast 1st lesion mr imag","19085","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8959",,,,,,,"fee schedule","7721","9357",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5921",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8707",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6486",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7346",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7282",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7812",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7346",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6616",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7312",,,,,,,"fee schedule","5921","8707",
"Removal of breast lesion","19120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8707",,,,,,,"fee schedule","5921","8707",
"Excision breast lesion","19125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15041",,,,,,,"fee schedule","12959","15710",
"Excision breast lesion","19125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13864",,,,,,,"fee schedule","12959","15710",
"Excision breast lesion","19125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15710",,,,,,,"fee schedule","12959","15710",
"Excision breast lesion","19125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15710",,,,,,,"fee schedule","12959","15710",
"Excision breast lesion","19125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12959",,,,,,,"fee schedule","12959","15710",
"Excision breast lesion","19125","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14324",,,,,,,"fee schedule","12959","15710",
"Excision breast lesion","19125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15041",,,,,,,"fee schedule","12959","15710",
"Perq dev breast 1st us imag","19285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4831",,,,,,,"fee schedule","3894","4831",
"Perq dev breast 1st us imag","19285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3894",,,,,,,"fee schedule","3894","4831",
"Perq dev breast 1st us imag","19285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4410",,,,,,,"fee schedule","3894","4831",
"Perq dev breast 1st us imag","19285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4410",,,,,,,"fee schedule","3894","4831",
"Perq dev breast 1st us imag","19285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4163",,,,,,,"fee schedule","3894","4831",
"Perq dev breast 1st us imag","19285","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4602",,,,,,,"fee schedule","3894","4831",
"Perq dev breast 1st us imag","19285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4831",,,,,,,"fee schedule","3894","4831",
"Partial Mastectomy","19301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","12960",,,,,,,"fee schedule","11168","13538",
"Partial Mastectomy","19301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13538",,,,,,,"fee schedule","11168","13538",
"Partial Mastectomy","19301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13538",,,,,,,"fee schedule","11168","13538",
"Partial Mastectomy","19301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11947",,,,,,,"fee schedule","11168","13538",
"Partial Mastectomy","19301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11168",,,,,,,"fee schedule","11168","13538",
"Partial Mastectomy","19301","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13208",,,,,,,"fee schedule","11168","13538",
"Partial Mastectomy","19301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","12960",,,,,,,"fee schedule","11168","13538",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15050",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","11338",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11645",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13345",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13345",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","14961",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","12818",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11781",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12671",,,,,,,"fee schedule","11338","15050",
"Reduction of large breast","19318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15050",,,,,,,"fee schedule","11338","15050",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","26669",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","25004",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18043",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","20211",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20441",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20441",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","21487",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","19032",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21037",,,,,,,"fee schedule","18043","26669",
"Enlarge breast with implant","19325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","25004",,,,,,,"fee schedule","18043","26669",
"Removal of breast capsule","19371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","21797",,,,,,,"fee schedule","18782","22767",
"Removal of breast capsule","19371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","22767",,,,,,,"fee schedule","18782","22767",
"Removal of breast capsule","19371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","18782",,,,,,,"fee schedule","18782","22767",
"Removal of breast capsule","19371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","22767",,,,,,,"fee schedule","18782","22767",
"Removal of breast capsule","19371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","20093",,,,,,,"fee schedule","18782","22767",
"Removal of breast capsule","19371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","21797",,,,,,,"fee schedule","18782","22767",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","727",,,,,,,"fee schedule","727","1006",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","901",,,,,,,"fee schedule","727","1006",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","959",,,,,,,"fee schedule","727","1006",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1006",,,,,,,"fee schedule","727","1006",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1006",,,,,,,"fee schedule","727","1006",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","795",,,,,,,"fee schedule","727","1006",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","888",,,,,,,"fee schedule","727","1006",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","913",,,,,,,"fee schedule","727","1006",
"Inject trigger points 3/>","20553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","901",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","727",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","901",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","959",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1006",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1006",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","888",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","795",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","913",,,,,,,"fee schedule","727","1006",
"Drain/inj joint/bursa w/o us","20610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","901",,,,,,,"fee schedule","727","1006",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6579",,,,,,,"fee schedule","4986","6642",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6166",,,,,,,"fee schedule","4986","6642",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4986",,,,,,,"fee schedule","4986","6642",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5702",,,,,,,"fee schedule","4986","6642",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6460",,,,,,,"fee schedule","4986","6642",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6460",,,,,,,"fee schedule","4986","6642",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6034",,,,,,,"fee schedule","4986","6642",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6642",,,,,,,"fee schedule","4986","6642",
"Removal of support implant","20680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6166",,,,,,,"fee schedule","4986","6642",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10847",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13432",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","17223",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9255",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11861",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13432",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8406",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9293",,,,,,,"fee schedule","8406","17223",
"Removal of tendon for graft","20924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","8406","17223",
"Removal of tissue for graft","20926","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6938",,,,,,,"fee schedule","6938","6938",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7205",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7751",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4882",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4822",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4379",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6098",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5385",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6098",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5856",,,,,,,"fee schedule","4379","7751",
"Closed tx nose fx w/ stablj","21320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7205",,,,,,,"fee schedule","4379","7751",
"Exc neck tum deep 5 cm/>","21554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16651",,,,,,,"fee schedule","14349","17391",
"Exc neck tum deep 5 cm/>","21554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15350",,,,,,,"fee schedule","14349","17391",
"Exc neck tum deep 5 cm/>","21554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17391",,,,,,,"fee schedule","14349","17391",
"Exc neck tum deep 5 cm/>","21554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17391",,,,,,,"fee schedule","14349","17391",
"Exc neck tum deep 5 cm/>","21554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14349",,,,,,,"fee schedule","14349","17391",
"Exc neck tum deep 5 cm/>","21554","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15861",,,,,,,"fee schedule","14349","17391",
"Exc neck tum deep 5 cm/>","21554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16651",,,,,,,"fee schedule","14349","17391",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4709",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4264",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4834",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3765",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3663",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4264",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4413",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4857",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4802",,,,,,,"fee schedule","3663","4857",
"Exc neck les sc < 3 cm","21555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4709",,,,,,,"fee schedule","3663","4857",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6438",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4986",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6579",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6460",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6034",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5702",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6460",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6642",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6564",,,,,,,"fee schedule","4986","6642",
"Exc neck tum deep < 5 cm","21556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6438",,,,,,,"fee schedule","4986","6642",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4709",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3663",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3765",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4834",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4264",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4264",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4413",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4857",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4802",,,,,,,"fee schedule","3663","4857",
"Exc back les sc < 3 cm","21930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4709",,,,,,,"fee schedule","3663","4857",
"Exc back les sc 3 cm/>","21931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","10706",,,,,,,"fee schedule","8967","10706",
"Exc back les sc 3 cm/>","21931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8967",,,,,,,"fee schedule","8967","10706",
"Exc back les sc 3 cm/>","21931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10155",,,,,,,"fee schedule","8967","10706",
"Exc back les sc 3 cm/>","21931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10155",,,,,,,"fee schedule","8967","10706",
"Exc back les sc 3 cm/>","21931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9224",,,,,,,"fee schedule","8967","10706",
"Exc back les sc 3 cm/>","21931","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10196",,,,,,,"fee schedule","8967","10706",
"Exc back les sc 3 cm/>","21931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","10706",,,,,,,"fee schedule","8967","10706",
"Exc back tum deep 5 cm/>","21933","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","14801",,,,,,,"fee schedule","12754","15460",
"Exc back tum deep 5 cm/>","21933","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12754",,,,,,,"fee schedule","12754","15460",
"Exc back tum deep 5 cm/>","21933","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13644",,,,,,,"fee schedule","12754","15460",
"Exc back tum deep 5 cm/>","21933","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15460",,,,,,,"fee schedule","12754","15460",
"Exc back tum deep 5 cm/>","21933","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15460",,,,,,,"fee schedule","12754","15460",
"Exc back tum deep 5 cm/>","21933","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14098",,,,,,,"fee schedule","12754","15460",
"Exc back tum deep 5 cm/>","21933","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","14801",,,,,,,"fee schedule","12754","15460",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8969",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8460",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9585",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7108",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9380",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8406",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9585",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9255",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8969",,,,,,,"fee schedule","7108","9585",
"Partial removal collar bone","23120","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9144",,,,,,,"fee schedule","7108","9585",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12421",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10280",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14071",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13565",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12514",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14071",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13552",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13397",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff acute","23410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10280",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14071",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12514",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13565",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14071",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12421",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13552",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13831",,,,,,,"fee schedule","10280","16750",
"Repair rotator cuff chronic","23412","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","10280","16750",
"Treat clavicle fracture","23515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","39938",,,,,,,"fee schedule","34416","41716",
"Treat clavicle fracture","23515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41716",,,,,,,"fee schedule","34416","41716",
"Treat clavicle fracture","23515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36813",,,,,,,"fee schedule","34416","41716",
"Treat clavicle fracture","23515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41716",,,,,,,"fee schedule","34416","41716",
"Treat clavicle fracture","23515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","34416",,,,,,,"fee schedule","34416","41716",
"Treat clavicle fracture","23515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","39938",,,,,,,"fee schedule","34416","41716",
"Treat humerus fracture","23615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","52901",,,,,,,"fee schedule","45585","55255",
"Treat humerus fracture","23615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","48763",,,,,,,"fee schedule","45585","55255",
"Treat humerus fracture","23615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","55255",,,,,,,"fee schedule","45585","55255",
"Treat humerus fracture","23615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","55255",,,,,,,"fee schedule","45585","55255",
"Treat humerus fracture","23615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","45585",,,,,,,"fee schedule","45585","55255",
"Treat humerus fracture","23615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","52901",,,,,,,"fee schedule","45585","55255",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4279",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4149",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4295",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4009",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3145",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3791",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4295",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4414",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4363",,,,,,,"fee schedule","3145","4414",
"Fixation of shoulder","23700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4279",,,,,,,"fee schedule","3145","4414",
"Repair arm tendon/muscle","24341","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","27849",,,,,,,"fee schedule","23998","29089",
"Repair arm tendon/muscle","24341","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","25671",,,,,,,"fee schedule","23998","29089",
"Repair arm tendon/muscle","24341","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","29089",,,,,,,"fee schedule","23998","29089",
"Repair arm tendon/muscle","24341","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","29089",,,,,,,"fee schedule","23998","29089",
"Repair arm tendon/muscle","24341","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","23998",,,,,,,"fee schedule","23998","29089",
"Repair arm tendon/muscle","24341","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","26526",,,,,,,"fee schedule","23998","29089",
"Repair arm tendon/muscle","24341","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","27849",,,,,,,"fee schedule","23998","29089",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8969",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9380",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8460",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9585",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5973",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7108",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9585",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7662",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9144",,,,,,,"fee schedule","5973","9585",
"Repair elbow perc","24357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8969",,,,,,,"fee schedule","5973","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9380",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8969",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8460",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9585",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7108",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8406",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9585",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9255",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9144",,,,,,,"fee schedule","7108","9585",
"Repair elbow w/deb open","24358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8969",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9380",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8969",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8406",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7108",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9585",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8460",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9585",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9255",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9144",,,,,,,"fee schedule","7108","9585",
"Repair elbow deb/attch open","24359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8969",,,,,,,"fee schedule","7108","9585",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4536",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6111",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5383",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5985",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6100",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6100",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5726",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6305",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6111",,,,,,,"fee schedule","4536","6305",
"Incision of tendon sheath","25000","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6233",,,,,,,"fee schedule","4536","6305",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5614",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4536",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6100",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5985",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6100",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5383",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5726",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6305",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6330",,,,,,,"fee schedule","4536","6330",
"Remove wrist tendon lesion","25111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5614",,,,,,,"fee schedule","4536","6330",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","12130",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11411",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9191",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10257",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11619",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11619",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","10695",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11774",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11635",,,,,,,"fee schedule","9191","12130",
"Repair wrist joints","25447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11411",,,,,,,"fee schedule","9191","12130",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7242",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7488",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7473",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6609",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7488",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5580",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7363",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6789",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7386",,,,,,,"fee schedule","5580","7488",
"Treat Fx Distal Radial","25606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7242",,,,,,,"fee schedule","5580","7488",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","18859",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","20627",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17678",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","27219",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17681",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20033",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20033",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","19458",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","18859",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Extra-Articul","25607","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19231",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","18859",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","20627",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17678",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","27219",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20033",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17681",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20033",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","19458",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19231",,,,,,,"fee schedule","17678","27219",
"Treat Fx Rad Intra-Articul","25608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","18859",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","18859",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","20627",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20033",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","27219",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","19458",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17681",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20033",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17678",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19231",,,,,,,"fee schedule","17678","27219",
"Treat Fx Radial 3+ Frag","25609","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","18859",,,,,,,"fee schedule","17678","27219",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3355",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4760",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4653",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4908",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4429",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4653",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4108",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4458",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4848",,,,,,,"fee schedule","3355","4908",
"Incise finger tendon sheath","26055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4760",,,,,,,"fee schedule","3355","4908",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4709",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3663",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4834",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4264",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3765",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4264",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4857",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4413",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4802",,,,,,,"fee schedule","3663","4857",
"Exc hand les sc < 1.5 cm","26115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4709",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4834",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3663",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4709",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4264",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4857",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4264",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3765",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4413",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4802",,,,,,,"fee schedule","3663","4857",
"Exc hand tum deep < 1.5 cm","26116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4709",,,,,,,"fee schedule","3663","4857",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7987",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7320",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8236",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","6037",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7966",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8294",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8294",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7483",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8142",,,,,,,"fee schedule","6037","8294",
"Release palm contracture","26123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7987",,,,,,,"fee schedule","6037","8294",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4760",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3355",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4429",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4653",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4653",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4108",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4458",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4908",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4848",,,,,,,"fee schedule","3355","4908",
"Remove tendon sheath lesion","26160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4760",,,,,,,"fee schedule","3355","4908",
"Repair hand joint","26540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","22132",,,,,,,"fee schedule","17957","22132",
"Repair hand joint","26540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17957",,,,,,,"fee schedule","17957","22132",
"Repair hand joint","26540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20337",,,,,,,"fee schedule","17957","22132",
"Repair hand joint","26540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20337",,,,,,,"fee schedule","17957","22132",
"Repair hand joint","26540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","19071",,,,,,,"fee schedule","17957","22132",
"Repair hand joint","26540","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21080",,,,,,,"fee schedule","17957","22132",
"Repair hand joint","26540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","22132",,,,,,,"fee schedule","17957","22132",
"Treat metacarpal fracture","26615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","22057",,,,,,,"fee schedule","17957","22057",
"Treat metacarpal fracture","26615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20337",,,,,,,"fee schedule","17957","22057",
"Treat metacarpal fracture","26615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17957",,,,,,,"fee schedule","17957","22057",
"Treat metacarpal fracture","26615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20337",,,,,,,"fee schedule","17957","22057",
"Treat metacarpal fracture","26615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","19007",,,,,,,"fee schedule","17957","22057",
"Treat metacarpal fracture","26615","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21007",,,,,,,"fee schedule","17957","22057",
"Treat metacarpal fracture","26615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","22057",,,,,,,"fee schedule","17957","22057",
"Treat finger fracture each","26735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","22081",,,,,,,"fee schedule","17957","22081",
"Treat finger fracture each","26735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20337",,,,,,,"fee schedule","17957","22081",
"Treat finger fracture each","26735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17957",,,,,,,"fee schedule","17957","22081",
"Treat finger fracture each","26735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20337",,,,,,,"fee schedule","17957","22081",
"Treat finger fracture each","26735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","19027",,,,,,,"fee schedule","17957","22081",
"Treat finger fracture each","26735","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21031",,,,,,,"fee schedule","17957","22081",
"Treat finger fracture each","26735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","22081",,,,,,,"fee schedule","17957","22081",
"Total hip arthroplasty","27130","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","63249",,,,,,,"fee schedule","63249","63249",
"Repair of kneecap tendon","27380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","39429",,,,,,,"fee schedule","33976","41185",
"Repair of kneecap tendon","27380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41185",,,,,,,"fee schedule","33976","41185",
"Repair of kneecap tendon","27380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41185",,,,,,,"fee schedule","33976","41185",
"Repair of kneecap tendon","27380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36344",,,,,,,"fee schedule","33976","41185",
"Repair of kneecap tendon","27380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","33976",,,,,,,"fee schedule","33976","41185",
"Repair of kneecap tendon","27380","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","36615",,,,,,,"fee schedule","33976","41185",
"Repair of kneecap tendon","27380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","39429",,,,,,,"fee schedule","33976","41185",
"Reconstruction knee","27427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","45428",,,,,,,"fee schedule","39146","45428",
"Reconstruction knee","27427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","39536",,,,,,,"fee schedule","39146","45428",
"Reconstruction knee","27427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","44774",,,,,,,"fee schedule","39146","45428",
"Reconstruction knee","27427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","39146",,,,,,,"fee schedule","39146","45428",
"Reconstruction knee","27427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","44774",,,,,,,"fee schedule","39146","45428",
"Reconstruction knee","27427","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","43269",,,,,,,"fee schedule","39146","45428",
"Reconstruction knee","27427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","45428",,,,,,,"fee schedule","39146","45428",
"Total knee arthroplasty","27447","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","64740",,,,,,,"fee schedule","64740","64740",
"Treat kneecap fracture","27524","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","39635",,,,,,,"fee schedule","34154","41400",
"Treat kneecap fracture","27524","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36535",,,,,,,"fee schedule","34154","41400",
"Treat kneecap fracture","27524","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41400",,,,,,,"fee schedule","34154","41400",
"Treat kneecap fracture","27524","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41400",,,,,,,"fee schedule","34154","41400",
"Treat kneecap fracture","27524","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","34154",,,,,,,"fee schedule","34154","41400",
"Treat kneecap fracture","27524","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37752",,,,,,,"fee schedule","34154","41400",
"Treat kneecap fracture","27524","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","39635",,,,,,,"fee schedule","34154","41400",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10280",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14071",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13565",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12311",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14071",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12421",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","12611",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16755",,,,,,,"fee schedule","10280","16755",
"Repair achilles tendon","27650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","10280","16755",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","17223",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10847",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11861",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13432",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13432",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8406",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9255",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14061",,,,,,,"fee schedule","8406","17223",
"Repair of ankle ligament","27698","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","8406","17223",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13546",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","11553",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","15243",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15349",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15349",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12948",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","14251",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14085",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","11553","16750",
"Treatment of ankle fracture","27814","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","43011",,,,,,,"fee schedule","37064","44925",
"Treatment of ankle fracture","27814","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","44925",,,,,,,"fee schedule","37064","44925",
"Treatment of ankle fracture","27814","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","39648",,,,,,,"fee schedule","37064","44925",
"Treatment of ankle fracture","27814","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","44925",,,,,,,"fee schedule","37064","44925",
"Treatment of ankle fracture","27814","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","37064",,,,,,,"fee schedule","37064","44925",
"Treatment of ankle fracture","27814","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","39943",,,,,,,"fee schedule","37064","44925",
"Treatment of ankle fracture","27814","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","43011",,,,,,,"fee schedule","37064","44925",
"Treat lower leg joint","27829","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","39852",,,,,,,"fee schedule","34339","41626",
"Treat lower leg joint","27829","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41626",,,,,,,"fee schedule","34339","41626",
"Treat lower leg joint","27829","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41626",,,,,,,"fee schedule","34339","41626",
"Treat lower leg joint","27829","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36735",,,,,,,"fee schedule","34339","41626",
"Treat lower leg joint","27829","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","34339",,,,,,,"fee schedule","34339","41626",
"Treat lower leg joint","27829","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37006",,,,,,,"fee schedule","34339","41626",
"Treat lower leg joint","27829","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","39852",,,,,,,"fee schedule","34339","41626",
"Incision of foot fascia","28008","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","18156",,,,,,,"fee schedule","15645","18965",
"Incision of foot fascia","28008","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16734",,,,,,,"fee schedule","15645","18965",
"Incision of foot fascia","28008","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18965",,,,,,,"fee schedule","15645","18965",
"Incision of foot fascia","28008","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18965",,,,,,,"fee schedule","15645","18965",
"Incision of foot fascia","28008","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","15645",,,,,,,"fee schedule","15645","18965",
"Incision of foot fascia","28008","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17293",,,,,,,"fee schedule","15645","18965",
"Incision of foot fascia","28008","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","18156",,,,,,,"fee schedule","15645","18965",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6542",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6840",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4753",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5382",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4307",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5382",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4857",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4413",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5788",,,,,,,"fee schedule","4307","6840",
"Exc foot/toe tum deep <1.5cm","28045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6542",,,,,,,"fee schedule","4307","6840",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6284",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6116",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6266",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4762",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5734",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6266",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5531",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6313",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6240",,,,,,,"fee schedule","4762","6313",
"Removal of foot lesion","28080","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6116",,,,,,,"fee schedule","4762","6313",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7540",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6284",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6266",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5734",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4762",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6266",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5531",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6313",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6240",,,,,,,"fee schedule","4762","7540",
"Part removal of metatarsal","28110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7540",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7540",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4762",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6284",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6483",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5719",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6483",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6313",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6032",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6240",,,,,,,"fee schedule","4762","7540",
"Removal of heel spur","28119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7540",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7540",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6483",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4762",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6284",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6313",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5719",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6483",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6032",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6240",,,,,,,"fee schedule","4762","7540",
"Part removal of ankle/heel","28120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7540",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7540",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4762",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6266",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6284",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5734",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6313",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6266",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5531",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6240",,,,,,,"fee schedule","4762","7540",
"Partial removal of foot bone","28122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7540",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7540",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4762",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6266",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6313",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6284",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5531",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6266",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5734",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6240",,,,,,,"fee schedule","4762","7540",
"Repair of hammertoe","28285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7540",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4762",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7540",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6284",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6483",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5719",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6483",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6032",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6313",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7540",,,,,,,"fee schedule","4762","7540",
"Corrj halux rigdus w/o implt","28289","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6240",,,,,,,"fee schedule","4762","7540",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","9051",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7311",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9649",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8584",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9727",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9727",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9340",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8485",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9234",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28292","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","9051",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","9051",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7311",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9649",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9340",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9727",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8584",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9727",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8485",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9234",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","9051",,,,,,,"fee schedule","7311","9727",
"Correction hallux valgus","28297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","40162",,,,,,,"fee schedule","34606","41948",
"Correction hallux valgus","28297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","37020",,,,,,,"fee schedule","34606","41948",
"Correction hallux valgus","28297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41948",,,,,,,"fee schedule","34606","41948",
"Correction hallux valgus","28297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","34606",,,,,,,"fee schedule","34606","41948",
"Correction hallux valgus","28297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41948",,,,,,,"fee schedule","34606","41948",
"Correction hallux valgus","28297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","40162",,,,,,,"fee schedule","34606","41948",
"Correction hallux valgus","28298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","27252",,,,,,,"fee schedule","23484","28464",
"Correction hallux valgus","28298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","23484",,,,,,,"fee schedule","23484","28464",
"Correction hallux valgus","28298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","28464",,,,,,,"fee schedule","23484","28464",
"Correction hallux valgus","28298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","25121",,,,,,,"fee schedule","23484","28464",
"Correction hallux valgus","28298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","28464",,,,,,,"fee schedule","23484","28464",
"Correction hallux valgus","28298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","27252",,,,,,,"fee schedule","23484","28464",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","17223",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11861",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9340",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10847",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13432",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13432",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8485",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16755",,,,,,,"fee schedule","8485","17223",
"Correction hallux valgus","28299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","8485","17223",
"Treat metatarsal fracture","28485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","29080",,,,,,,"fee schedule","25058","30374",
"Treat metatarsal fracture","28485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","26805",,,,,,,"fee schedule","25058","30374",
"Treat metatarsal fracture","28485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","25058",,,,,,,"fee schedule","25058","30374",
"Treat metatarsal fracture","28485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","30374",,,,,,,"fee schedule","25058","30374",
"Treat metatarsal fracture","28485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","30374",,,,,,,"fee schedule","25058","30374",
"Treat metatarsal fracture","28485","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","27697",,,,,,,"fee schedule","25058","30374",
"Treat metatarsal fracture","28485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","29080",,,,,,,"fee schedule","25058","30374",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16152",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","14259",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15992",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","16662",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","15140",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","18814",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18117",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18117",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16471",,,,,,,"fee schedule","14259","18814",
"Fusion of big toe joint","28750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16152",,,,,,,"fee schedule","14259","18814",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13987",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15846",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","11874",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","15665",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15846",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","16280",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14787",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13987",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15846",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","15665",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","11874",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","16280",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15846",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14787",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29807","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","11874","16750",
"Shoulder arthroscopy/surgery","29822","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","22047",,,,,,,"fee schedule","17957","22047",
"Shoulder arthroscopy/surgery","29822","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20337",,,,,,,"fee schedule","17957","22047",
"Shoulder arthroscopy/surgery","29822","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17957",,,,,,,"fee schedule","17957","22047",
"Shoulder arthroscopy/surgery","29822","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20337",,,,,,,"fee schedule","17957","22047",
"Shoulder arthroscopy/surgery","29822","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","18999",,,,,,,"fee schedule","17957","22047",
"Shoulder arthroscopy/surgery","29822","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","22047",,,,,,,"fee schedule","17957","22047",
"Shoulder arthroscopy/surgery","29823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","21176",,,,,,,"fee schedule","17957","21176",
"Shoulder arthroscopy/surgery","29823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17957",,,,,,,"fee schedule","17957","21176",
"Shoulder arthroscopy/surgery","29823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20337",,,,,,,"fee schedule","17957","21176",
"Shoulder arthroscopy/surgery","29823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20337",,,,,,,"fee schedule","17957","21176",
"Shoulder arthroscopy/surgery","29823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","18248",,,,,,,"fee schedule","17957","21176",
"Shoulder arthroscopy/surgery","29823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","21176",,,,,,,"fee schedule","17957","21176",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","15665",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","14685",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","11874",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15846",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13987",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15846",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","12144",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29824","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","14685",,,,,,,"fee schedule","7691","15846",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3514",,,,,,,"fee schedule","2842","8468",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2842",,,,,,,"fee schedule","2842","8468",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3750",,,,,,,"fee schedule","2842","8468",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","2842","8468",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3895",,,,,,,"fee schedule","2842","8468",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3438",,,,,,,"fee schedule","2842","8468",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3895",,,,,,,"fee schedule","2842","8468",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","2842","8468",
"Shoulder arthroscopy/surgery","29826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3514",,,,,,,"fee schedule","2842","8468",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","11874",,,,,,,"fee schedule","11874","16750",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","15665",,,,,,,"fee schedule","11874","16750",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16750",,,,,,,"fee schedule","11874","16750",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","16280",,,,,,,"fee schedule","11874","16750",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15846",,,,,,,"fee schedule","11874","16750",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14787",,,,,,,"fee schedule","11874","16750",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13987",,,,,,,"fee schedule","11874","16750",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15846",,,,,,,"fee schedule","11874","16750",
"Arthroscop rotator cuff repr","29827","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16750",,,,,,,"fee schedule","11874","16750",
"Arthroscopy biceps tenodesis","29828","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","27075",,,,,,,"fee schedule","23331","28279",
"Arthroscopy biceps tenodesis","29828","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","24957",,,,,,,"fee schedule","23331","28279",
"Arthroscopy biceps tenodesis","29828","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","28279",,,,,,,"fee schedule","23331","28279",
"Arthroscopy biceps tenodesis","29828","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","23331",,,,,,,"fee schedule","23331","28279",
"Arthroscopy biceps tenodesis","29828","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","28279",,,,,,,"fee schedule","23331","28279",
"Arthroscopy biceps tenodesis","29828","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","27075",,,,,,,"fee schedule","23331","28279",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","5877","8468",
"Wrist arthroscopy/surgery","29846","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8370",,,,,,,"fee schedule","5877","8468",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5973",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7662",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3276",,,,,,,"fee schedule","3276","8209",
"Wrist endoscopy/surgery","29848","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","3276","8209",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8370",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8370",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29876","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","18082",,,,,,,"fee schedule","15581","18886",
"Knee arthroscopy/surgery","29876","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16667",,,,,,,"fee schedule","15581","18886",
"Knee arthroscopy/surgery","29876","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18886",,,,,,,"fee schedule","15581","18886",
"Knee arthroscopy/surgery","29876","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18886",,,,,,,"fee schedule","15581","18886",
"Knee arthroscopy/surgery","29876","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","15581",,,,,,,"fee schedule","15581","18886",
"Knee arthroscopy/surgery","29876","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17221",,,,,,,"fee schedule","15581","18886",
"Knee arthroscopy/surgery","29876","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","18082",,,,,,,"fee schedule","15581","18886",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8370",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8370",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29879","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8370",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29880","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8370",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5877",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7755",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8468",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8023",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7081",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7691",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8370",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8209",,,,,,,"fee schedule","5877","8468",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","24558",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","22793",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","17274",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","25331",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","24213",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","24213",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","21372",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","23015",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","25040",,,,,,,"fee schedule","17274","25331",
"Knee arthroscopy/surgery","29888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","24558",,,,,,,"fee schedule","17274","25331",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6284",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7540",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4762",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6266",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5531",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6266",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5734",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6313",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6240",,,,,,,"fee schedule","4762","7540",
"Scope plantar fasciotomy","29893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7540",,,,,,,"fee schedule","4762","7540",
"Hip arthro w/labral repair","29916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","48425",,,,,,,"fee schedule","39536","48425",
"Hip arthro w/labral repair","29916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","39536",,,,,,,"fee schedule","39536","48425",
"Hip arthro w/labral repair","29916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","44774",,,,,,,"fee schedule","39536","48425",
"Hip arthro w/labral repair","29916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","44774",,,,,,,"fee schedule","39536","48425",
"Hip arthro w/labral repair","29916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","41728",,,,,,,"fee schedule","39536","48425",
"Hip arthro w/labral repair","29916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","48425",,,,,,,"fee schedule","39536","48425",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7205",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5315",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6915",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7015",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6106",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6915",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6462",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7113",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7205",,,,,,,"fee schedule","5315","7205",
"Resect inferior turbinate","30140","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7143",,,,,,,"fee schedule","5315","7205",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6894",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5315",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6106",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6915",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7015",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6915",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6462",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7113",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7030",,,,,,,"fee schedule","5315","7113",
"Repair of nasal septum","30520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6894",,,,,,,"fee schedule","5315","7113",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7205",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7015",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5315",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4379",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6915",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6106",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6915",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4822",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7205",,,,,,,"fee schedule","4379","7205",
"Ther fx nasal inf turbinate","30930","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5856",,,,,,,"fee schedule","4379","7205",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15668",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13016",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7891",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10376",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","16478",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11494",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13016",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8682",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15672",,,,,,,"fee schedule","7891","16478",
"Revision of ethmoid sinus","31254","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15668",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15668",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7891",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11494",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13016",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10376",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","16478",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13016",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8682",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15672",,,,,,,"fee schedule","7891","16478",
"Removal of ethmoid sinus","31255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15668",,,,,,,"fee schedule","7891","16478",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8420",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7248",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5493",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6176",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6999",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6999",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7891",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8682",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8583",,,,,,,"fee schedule","5493","8682",
"Exploration maxillary sinus","31256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8420",,,,,,,"fee schedule","5493","8682",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15668",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11494",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13016",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10376",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","16478",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13016",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7891",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8682",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15672",,,,,,,"fee schedule","7891","16478",
"Endoscopy maxillary sinus","31267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15668",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15668",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11494",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13016",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10376",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","16478",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13016",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8682",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7891",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15672",,,,,,,"fee schedule","7891","16478",
"Sinus endoscopy surgical","31276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15668",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10376",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","16478",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15668",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","8682",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13016",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11494",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13016",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7891",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15672",,,,,,,"fee schedule","7891","16478",
"Nasal/sinus endoscopy surg","31288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15668",,,,,,,"fee schedule","7891","16478",
"Laryngoscopy w/biopsy","31535","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19413",,,,,,,"fee schedule","16729","20277",
"Laryngoscopy w/biopsy","31535","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16729",,,,,,,"fee schedule","16729","20277",
"Laryngoscopy w/biopsy","31535","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17894",,,,,,,"fee schedule","16729","20277",
"Laryngoscopy w/biopsy","31535","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20277",,,,,,,"fee schedule","16729","20277",
"Laryngoscopy w/biopsy","31535","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20277",,,,,,,"fee schedule","16729","20277",
"Laryngoscopy w/biopsy","31535","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18489",,,,,,,"fee schedule","16729","20277",
"Laryngoscopy w/biopsy","31535","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19413",,,,,,,"fee schedule","16729","20277",
"Larynscop w/tumr exc + scope","31541","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19640",,,,,,,"fee schedule","16924","20515",
"Larynscop w/tumr exc + scope","31541","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20515",,,,,,,"fee schedule","16924","20515",
"Larynscop w/tumr exc + scope","31541","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16924",,,,,,,"fee schedule","16924","20515",
"Larynscop w/tumr exc + scope","31541","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20515",,,,,,,"fee schedule","16924","20515",
"Larynscop w/tumr exc + scope","31541","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18104",,,,,,,"fee schedule","16924","20515",
"Larynscop w/tumr exc + scope","31541","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18706",,,,,,,"fee schedule","16924","20515",
"Larynscop w/tumr exc + scope","31541","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19640",,,,,,,"fee schedule","16924","20515",
"Bronch ebus samplng 1/2 node","31652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19496",,,,,,,"fee schedule","16800","20364",
"Bronch ebus samplng 1/2 node","31652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17971",,,,,,,"fee schedule","16800","20364",
"Bronch ebus samplng 1/2 node","31652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20364",,,,,,,"fee schedule","16800","20364",
"Bronch ebus samplng 1/2 node","31652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20364",,,,,,,"fee schedule","16800","20364",
"Bronch ebus samplng 1/2 node","31652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16800",,,,,,,"fee schedule","16800","20364",
"Bronch ebus samplng 1/2 node","31652","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18570",,,,,,,"fee schedule","16800","20364",
"Bronch ebus samplng 1/2 node","31652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19496",,,,,,,"fee schedule","16800","20364",
"Bronch ebus samplng 3/> node","31653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19460",,,,,,,"fee schedule","16769","20324",
"Bronch ebus samplng 3/> node","31653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17937",,,,,,,"fee schedule","16769","20324",
"Bronch ebus samplng 3/> node","31653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20324",,,,,,,"fee schedule","16769","20324",
"Bronch ebus samplng 3/> node","31653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20324",,,,,,,"fee schedule","16769","20324",
"Bronch ebus samplng 3/> node","31653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16769",,,,,,,"fee schedule","16769","20324",
"Bronch ebus samplng 3/> node","31653","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18072",,,,,,,"fee schedule","16769","20324",
"Bronch ebus samplng 3/> node","31653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19460",,,,,,,"fee schedule","16769","20324",
"Percut bx lung/mediastinum","32405","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8761",,,,,,,"fee schedule","8761","8761",
"Core ndl bx lng/med perq","32408","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10620",,,,,,,"fee schedule","9684","10620",
"Core ndl bx lng/med perq","32408","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10620",,,,,,,"fee schedule","9684","10620",
"Core ndl bx lng/med perq","32408","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10620",,,,,,,"fee schedule","9684","10620",
"Core ndl bx lng/med perq","32408","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9684",,,,,,,"fee schedule","9684","10620",
"Insert pleural cath","32550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19946",,,,,,,"fee schedule","17188","20834",
"Insert pleural cath","32550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18386",,,,,,,"fee schedule","17188","20834",
"Insert pleural cath","32550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20834",,,,,,,"fee schedule","17188","20834",
"Insert pleural cath","32550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20834",,,,,,,"fee schedule","17188","20834",
"Insert pleural cath","32550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17188",,,,,,,"fee schedule","17188","20834",
"Insert pleural cath","32550","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18998",,,,,,,"fee schedule","17188","20834",
"Insert pleural cath","32550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19946",,,,,,,"fee schedule","17188","20834",
"Insert tunneled cv cath","36561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16449",,,,,,,"fee schedule","14174","17180",
"Insert tunneled cv cath","36561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15161",,,,,,,"fee schedule","14174","17180",
"Insert tunneled cv cath","36561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14174",,,,,,,"fee schedule","14174","17180",
"Insert tunneled cv cath","36561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17180",,,,,,,"fee schedule","14174","17180",
"Insert tunneled cv cath","36561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17180",,,,,,,"fee schedule","14174","17180",
"Insert tunneled cv cath","36561","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15667",,,,,,,"fee schedule","14174","17180",
"Insert tunneled cv cath","36561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16449",,,,,,,"fee schedule","14174","17180",
"Av fusion direct any site","36821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","22145",,,,,,,"fee schedule","17420","22145",
"Av fusion direct any site","36821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19728",,,,,,,"fee schedule","17420","22145",
"Av fusion direct any site","36821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","19084",,,,,,,"fee schedule","17420","22145",
"Av fusion direct any site","36821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19728",,,,,,,"fee schedule","17420","22145",
"Av fusion direct any site","36821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17420",,,,,,,"fee schedule","17420","22145",
"Av fusion direct any site","36821","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21093",,,,,,,"fee schedule","17420","22145",
"Av fusion direct any site","36821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","22145",,,,,,,"fee schedule","17420","22145",
"Rem endovas vena cava filter","37193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","18041",,,,,,,"fee schedule","15546","18844",
"Rem endovas vena cava filter","37193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16630",,,,,,,"fee schedule","15546","18844",
"Rem endovas vena cava filter","37193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18844",,,,,,,"fee schedule","15546","18844",
"Rem endovas vena cava filter","37193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18844",,,,,,,"fee schedule","15546","18844",
"Rem endovas vena cava filter","37193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","15546",,,,,,,"fee schedule","15546","18844",
"Rem endovas vena cava filter","37193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","18041",,,,,,,"fee schedule","15546","18844",
"Rem endovas vena cava filter","37193","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17183",,,,,,,"fee schedule","15546","18844",
"Phleb veins - extrem 20+","37766","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","21520",,,,,,,"fee schedule","17420","21520",
"Phleb veins - extrem 20+","37766","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19728",,,,,,,"fee schedule","17420","21520",
"Phleb veins - extrem 20+","37766","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19728",,,,,,,"fee schedule","17420","21520",
"Phleb veins - extrem 20+","37766","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17420",,,,,,,"fee schedule","17420","21520",
"Phleb veins - extrem 20+","37766","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","18545",,,,,,,"fee schedule","17420","21520",
"Phleb veins - extrem 20+","37766","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","20497",,,,,,,"fee schedule","17420","21520",
"Phleb veins - extrem 20+","37766","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","21520",,,,,,,"fee schedule","17420","21520",
"Bone marrow biopsy","38221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","10268",,,,,,,"fee schedule","8847","10268",
"Bone marrow biopsy","38221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8967",,,,,,,"fee schedule","8847","10268",
"Bone marrow biopsy","38221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10155",,,,,,,"fee schedule","8847","10268",
"Bone marrow biopsy","38221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8847",,,,,,,"fee schedule","8847","10268",
"Bone marrow biopsy","38221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10155",,,,,,,"fee schedule","8847","10268",
"Bone marrow biopsy","38221","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9780",,,,,,,"fee schedule","8847","10268",
"Bone marrow biopsy","38221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","10268",,,,,,,"fee schedule","8847","10268",
"Biopsy/removal lymph nodes","38500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19851",,,,,,,"fee schedule","17105","20734",
"Biopsy/removal lymph nodes","38500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17105",,,,,,,"fee schedule","17105","20734",
"Biopsy/removal lymph nodes","38500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18298",,,,,,,"fee schedule","17105","20734",
"Biopsy/removal lymph nodes","38500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20734",,,,,,,"fee schedule","17105","20734",
"Biopsy/removal lymph nodes","38500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20734",,,,,,,"fee schedule","17105","20734",
"Biopsy/removal lymph nodes","38500","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18907",,,,,,,"fee schedule","17105","20734",
"Biopsy/removal lymph nodes","38500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19851",,,,,,,"fee schedule","17105","20734",
"Biopsy/removal lymph nodes","38510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","20107",,,,,,,"fee schedule","17326","21001",
"Biopsy/removal lymph nodes","38510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18532",,,,,,,"fee schedule","17326","21001",
"Biopsy/removal lymph nodes","38510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","21001",,,,,,,"fee schedule","17326","21001",
"Biopsy/removal lymph nodes","38510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","21001",,,,,,,"fee schedule","17326","21001",
"Biopsy/removal lymph nodes","38510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17326",,,,,,,"fee schedule","17326","21001",
"Biopsy/removal lymph nodes","38510","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19151",,,,,,,"fee schedule","17326","21001",
"Biopsy/removal lymph nodes","38510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","20107",,,,,,,"fee schedule","17326","21001",
"Open bx/exc inguinofem nodes","38531","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","24351",,,,,,,"fee schedule","20984","24351",
"Open bx/exc inguinofem nodes","38531","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","24001",,,,,,,"fee schedule","20984","24351",
"Open bx/exc inguinofem nodes","38531","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","21193",,,,,,,"fee schedule","20984","24351",
"Open bx/exc inguinofem nodes","38531","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","24001",,,,,,,"fee schedule","20984","24351",
"Open bx/exc inguinofem nodes","38531","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","20984",,,,,,,"fee schedule","20984","24351",
"Open bx/exc inguinofem nodes","38531","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","22614",,,,,,,"fee schedule","20984","24351",
"Open bx/exc inguinofem nodes","38531","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","24351",,,,,,,"fee schedule","20984","24351",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3480",,,,,,,"fee schedule","3348","4576",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3348",,,,,,,"fee schedule","3348","4576",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4417",,,,,,,"fee schedule","3348","4576",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4037",,,,,,,"fee schedule","3348","4576",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4576",,,,,,,"fee schedule","3348","4576",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4576",,,,,,,"fee schedule","3348","4576",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4198",,,,,,,"fee schedule","3348","4576",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3784",,,,,,,"fee schedule","3348","4576",
"Dental surgery procedure","41899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3480",,,,,,,"fee schedule","3348","4576",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13523",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11123",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11123",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","14099",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","8879",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6462",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9822",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7113",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13523",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42820","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11126",,,,,,,"fee schedule","6462","14099",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6894",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7015",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6915",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5315",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6462",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6915",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6106",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7113",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7030",,,,,,,"fee schedule","5315","7113",
"Remove tonsils and adenoids","42821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6894",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","12406",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13447",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10161",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11706",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13261",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10191",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11621",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13261",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12651",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42825","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","12406",,,,,,,"fee schedule","10161","13447",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7015",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6894",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6462",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5315",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7113",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6106",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6915",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6915",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7030",,,,,,,"fee schedule","5315","7113",
"Removal of tonsils","42826","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6894",,,,,,,"fee schedule","5315","7113",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","12406",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11706",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13261",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11621",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10191",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13447",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13261",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10161",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8105",,,,,,,"fee schedule","8105","13447",
"Removal of adenoids","42830","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","12406",,,,,,,"fee schedule","8105","13447",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2509",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2943",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2409",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2728",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2230",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3410",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2728",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3084",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2980",,,,,,,"fee schedule","2230","3410",
"Egd diagnostic brush wash","43235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2509",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2509",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2943",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3410",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2409",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2728",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2230",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2728",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3084",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2980",,,,,,,"fee schedule","2230","3410",
"Egd biopsy single/multiple","43239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2509",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2509",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2230",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2409",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2728",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2943",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2728",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3084",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3410",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2980",,,,,,,"fee schedule","2230","3410",
"Egd remove foreign body","43247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2509",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2230",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2509",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2943",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2728",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2409",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2728",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3084",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3410",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2980",,,,,,,"fee schedule","2230","3410",
"Egd guide wire insertion","43248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2509",,,,,,,"fee schedule","2230","3410",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4410",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4199",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3182",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4123",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4615",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4123",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3639",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","5107",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4465",,,,,,,"fee schedule","3182","5107",
"Esoph egd dilation <30 mm","43249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4410",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4199",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4410",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4123",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4123",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4615",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3182",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3639",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","5107",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4465",,,,,,,"fee schedule","3182","5107",
"Egd remove lesion snare","43251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4410",,,,,,,"fee schedule","3182","5107",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2105",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1944",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1656",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1474",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1876",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1876",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2275",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2513",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3306",,,,,,,"fee schedule","1474","3306",
"Diagnostic sigmoidoscopy","45330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2105",,,,,,,"fee schedule","1474","3306",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2780",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3110",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2357",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2997",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2646",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2997",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3783",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3419",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3306",,,,,,,"fee schedule","2357","3783",
"Diagnostic colonoscopy","45378","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2780",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3110",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2780",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2997",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2357",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3783",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2646",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2997",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3419",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3306",,,,,,,"fee schedule","2357","3783",
"Colonoscopy and biopsy","45380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2780",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3110",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2780",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2646",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2997",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3783",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2357",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2997",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3419",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2780",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45384","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3306",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2780",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3110",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2997",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2357",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3783",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2646",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2997",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3419",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3306",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/lesion removal","45385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2780",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2780",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2646",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2997",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3110",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2357",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2997",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3419",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3783",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3306",,,,,,,"fee schedule","2357","3783",
"Colonoscopy w/ablation","45388","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2780",,,,,,,"fee schedule","2357","3783",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Removal of anal fissure","46200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove ext hem groups 2+","46250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove int/ext hem 1 group","46255","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp & fiss","46257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grp w/fistu","46258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem groups 2+","46260","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove in/ex hem grps & fiss","46261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove anal fist subq","46270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove anal fist inter","46275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove anal fist complex","46280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7105",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6270",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7105",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","5305","7105",
"Remove anal fist 2 stage","46285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","5305","7105",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6755",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7106",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8214",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6968",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9378",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9306",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9306",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6333",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6886",,,,,,,"fee schedule","6333","9378",
"Repair anal fistula","46288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6755",,,,,,,"fee schedule","6333","9378",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5996",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6187",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5623",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5623",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4965",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5621",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6114",,,,,,,"fee schedule","4965","7000",
"Excision of anal lesion(s)","46922","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5996",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5996",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5305",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6187",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7000",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4965",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5623",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5623",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5621",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6114",,,,,,,"fee schedule","4965","7000",
"Destruction anal lesion(s)","46924","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5996",,,,,,,"fee schedule","4965","7000",
"Percut ablate liver rf","47382","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","36546",,,,,,,"fee schedule","31493","36568",
"Percut ablate liver rf","47382","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","31493",,,,,,,"fee schedule","31493","36568",
"Percut ablate liver rf","47382","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","36568",,,,,,,"fee schedule","31493","36568",
"Percut ablate liver rf","47382","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","32289",,,,,,,"fee schedule","31493","36568",
"Percut ablate liver rf","47382","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","36568",,,,,,,"fee schedule","31493","36568",
"Percut ablate liver rf","47382","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","36546",,,,,,,"fee schedule","31493","36568",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12454",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13579",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13579",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11983",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13708",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13549",,,,,,,"fee schedule","10324","13708",
"Laparoscopic cholecystectomy","47562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13579",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11983",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13579",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13708",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12454",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparo cholecystectomy/graph","47563","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13549",,,,,,,"fee schedule","10324","13708",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13199",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9623",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","8242",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","10875",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10904",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10904",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","10087",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11103",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11150",,,,,,,"fee schedule","8242","13199",
"Diag laparo separate proc","49320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13199",,,,,,,"fee schedule","8242","13199",
"Lap insert tunnel ip cath","49324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","30036",,,,,,,"fee schedule","25882","31372",
"Lap insert tunnel ip cath","49324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","31372",,,,,,,"fee schedule","25882","31372",
"Lap insert tunnel ip cath","49324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","31372",,,,,,,"fee schedule","25882","31372",
"Lap insert tunnel ip cath","49324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","27688",,,,,,,"fee schedule","25882","31372",
"Lap insert tunnel ip cath","49324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","25882",,,,,,,"fee schedule","25882","31372",
"Lap insert tunnel ip cath","49324","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","28608",,,,,,,"fee schedule","25882","31372",
"Lap insert tunnel ip cath","49324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","30036",,,,,,,"fee schedule","25882","31372",
"Rpr ing hernia init reduce","49500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11267",,,,,,,"fee schedule","11267","21304",
"Rpr ing hernia init reduce","49500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","21304",,,,,,,"fee schedule","11267","21304",
"Rpr ing hernia init reduce","49500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18802",,,,,,,"fee schedule","11267","21304",
"Rpr ing hernia init reduce","49500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","21304",,,,,,,"fee schedule","11267","21304",
"Rpr ing hernia init reduce","49500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17577",,,,,,,"fee schedule","11267","21304",
"Rpr ing hernia init reduce","49500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11808",,,,,,,"fee schedule","11267","21304",
"Rpr ing hernia init reduce","49500","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12356",,,,,,,"fee schedule","11267","21304",
"Rpr ing hernia init reduce","49500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11267",,,,,,,"fee schedule","11267","21304",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11267",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7308",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9643",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9673",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9673",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8537",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8541",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11808",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11267",,,,,,,"fee schedule","7308","11808",
"Prp i/hern init reduc >5 yr","49505","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9294",,,,,,,"fee schedule","7308","11808",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11267",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19531",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","19703",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7308",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9643",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","22119",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","22119",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11808",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12356",,,,,,,"fee schedule","7308","22119",
"Rerepair ing hernia reduce","49520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11267",,,,,,,"fee schedule","7308","22119",
"Rpr epigastric hern blocked","49572","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17547",,,,,,,"fee schedule","17547","17547",
"Rpr umbil hern reduc > 5 yr","49585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","8541",,,,,,,"fee schedule","8541","8541",
"Rpr umbil hern block > 5 yr","49587","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16518",,,,,,,"fee schedule","16518","16518",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11289",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11059",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7308",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9643",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11831",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11059",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11059",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12356",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11289",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16459",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","17251",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18016",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16459",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11289",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7308",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11831",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9643",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12356",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11289",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16459",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","17251",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18016",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16459",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11289",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11831",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7308",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9643",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11289",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12356",,,,,,,"fee schedule","7308","19552",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11289",,,,,,,"fee schedule","7308","12356",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7308",,,,,,,"fee schedule","7308","12356",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9643",,,,,,,"fee schedule","7308","12356",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11059",,,,,,,"fee schedule","7308","12356",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11059",,,,,,,"fee schedule","7308","12356",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11059",,,,,,,"fee schedule","7308","12356",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11831",,,,,,,"fee schedule","7308","12356",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12356",,,,,,,"fee schedule","7308","12356",
"Repair umbilical lesion","49600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11289",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7308",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9643",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11289",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11059",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11059",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11059",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11831",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12356",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11289",,,,,,,"fee schedule","7308","12356",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16459",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","17251",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18282",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18016",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16459",,,,,,,"fee schedule","10324","18282",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","7308",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","9643",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11289",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19552",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","11831",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12356",,,,,,,"fee schedule","7308","19552",
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11289",,,,,,,"fee schedule","7308","19552",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16459",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","17251",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13579",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11983",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13579",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12454",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13549",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair init","49650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16459",,,,,,,"fee schedule","10324","17251",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16459",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","17251",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","34277",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","30249",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","34277",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","28278",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16459",,,,,,,"fee schedule","10324","34277",
"Lap ing hernia repair recur","49651","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18016",,,,,,,"fee schedule","10324","34277",
"Lap vent/abd hern proc comp","49653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","32953",,,,,,,"fee schedule","32953","32953",
"Lap inc hernia repair recur","49656","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","52171",,,,,,,"fee schedule","52171","52171",
"Renal biopsy perq","50200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8829",,,,,,,"fee schedule","7608","9221",
"Renal biopsy perq","50200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9221",,,,,,,"fee schedule","7608","9221",
"Renal biopsy perq","50200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8138",,,,,,,"fee schedule","7608","9221",
"Renal biopsy perq","50200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9221",,,,,,,"fee schedule","7608","9221",
"Renal biopsy perq","50200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","7608",,,,,,,"fee schedule","7608","9221",
"Renal biopsy perq","50200","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8409",,,,,,,"fee schedule","7608","9221",
"Renal biopsy perq","50200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8829",,,,,,,"fee schedule","7608","9221",
"Laparoscopy pyeloplasty","50544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","68899",,,,,,,"fee schedule","57619","68899",
"Laparoscopy pyeloplasty","50544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","65254",,,,,,,"fee schedule","57619","68899",
"Laparoscopy pyeloplasty","50544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","59369",,,,,,,"fee schedule","57619","68899",
"Laparoscopy pyeloplasty","50544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","57619",,,,,,,"fee schedule","57619","68899",
"Laparoscopy pyeloplasty","50544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","65254",,,,,,,"fee schedule","57619","68899",
"Laparoscopy pyeloplasty","50544","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","65622",,,,,,,"fee schedule","57619","68899",
"Laparoscopy pyeloplasty","50544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","68899",,,,,,,"fee schedule","57619","68899",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","8506",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","14415",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9822",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11223",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11128",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11128",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","13510",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","14870",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14699",,,,,,,"fee schedule","8506","14870",
"Fragmenting of kidney stone","50590","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","14415",,,,,,,"fee schedule","8506","14870",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","882",,,,,,,"fee schedule","786","1525",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","786",,,,,,,"fee schedule","786","1525",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1251",,,,,,,"fee schedule","786","1525",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1347",,,,,,,"fee schedule","786","1525",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1525",,,,,,,"fee schedule","786","1525",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1525",,,,,,,"fee schedule","786","1525",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1247",,,,,,,"fee schedule","786","1525",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1392",,,,,,,"fee schedule","786","1525",
"Complex cystometrogram","51726","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","882",,,,,,,"fee schedule","786","1525",
"Cystoscopy","52000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1771",,,,,,,"fee schedule","1756","2006",
"Cystoscopy","52000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2006",,,,,,,"fee schedule","1756","2006",
"Cystoscopy","52000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2006",,,,,,,"fee schedule","1756","2006",
"Cystoscopy","52000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1936",,,,,,,"fee schedule","1756","2006",
"Cystoscopy","52000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1756",,,,,,,"fee schedule","1756","2006",
"Cystoscopy","52000","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1914",,,,,,,"fee schedule","1756","2006",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7272",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5696",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7469",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7514",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6594",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7469",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6820",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7506",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7416",,,,,,,"fee schedule","5696","7514",
"Cystoscopy & ureter catheter","52005","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7272",,,,,,,"fee schedule","5696","7514",
"Cystoscopy w/biopsy(s)","52204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13886",,,,,,,"fee schedule","11337","13886",
"Cystoscopy w/biopsy(s)","52204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11337",,,,,,,"fee schedule","11337","13886",
"Cystoscopy w/biopsy(s)","52204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12839",,,,,,,"fee schedule","11337","13886",
"Cystoscopy w/biopsy(s)","52204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12839",,,,,,,"fee schedule","11337","13886",
"Cystoscopy w/biopsy(s)","52204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11965",,,,,,,"fee schedule","11337","13886",
"Cystoscopy w/biopsy(s)","52204","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13225",,,,,,,"fee schedule","11337","13886",
"Cystoscopy w/biopsy(s)","52204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13886",,,,,,,"fee schedule","11337","13886",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8116",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7469",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5696",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7514",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6594",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7469",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6820",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7506",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7416",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8116",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19256",,,,,,,"fee schedule","16594","20113",
"Cystoscopy and treatment","52235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16594",,,,,,,"fee schedule","16594","20113",
"Cystoscopy and treatment","52235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20113",,,,,,,"fee schedule","16594","20113",
"Cystoscopy and treatment","52235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17750",,,,,,,"fee schedule","16594","20113",
"Cystoscopy and treatment","52235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20113",,,,,,,"fee schedule","16594","20113",
"Cystoscopy and treatment","52235","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18341",,,,,,,"fee schedule","16594","20113",
"Cystoscopy and treatment","52235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19256",,,,,,,"fee schedule","16594","20113",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4842",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3353",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4425",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3957",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4483",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4483",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4539",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4995",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4935",,,,,,,"fee schedule","3353","4995",
"Cystoscopy and treatment","52260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4842",,,,,,,"fee schedule","3353","4995",
"Remove bladder stone","52317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19345",,,,,,,"fee schedule","16671","20206",
"Remove bladder stone","52317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20206",,,,,,,"fee schedule","16671","20206",
"Remove bladder stone","52317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16671",,,,,,,"fee schedule","16671","20206",
"Remove bladder stone","52317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17832",,,,,,,"fee schedule","16671","20206",
"Remove bladder stone","52317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20206",,,,,,,"fee schedule","16671","20206",
"Remove bladder stone","52317","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18426",,,,,,,"fee schedule","16671","20206",
"Remove bladder stone","52317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19345",,,,,,,"fee schedule","16671","20206",
"Remove bladder stone","52318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","21870",,,,,,,"fee schedule","18845","22843",
"Remove bladder stone","52318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","18845",,,,,,,"fee schedule","18845","22843",
"Remove bladder stone","52318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","20159",,,,,,,"fee schedule","18845","22843",
"Remove bladder stone","52318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","22843",,,,,,,"fee schedule","18845","22843",
"Remove bladder stone","52318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","22843",,,,,,,"fee schedule","18845","22843",
"Remove bladder stone","52318","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","20829",,,,,,,"fee schedule","18845","22843",
"Remove bladder stone","52318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","21870",,,,,,,"fee schedule","18845","22843",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8116",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5696",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7514",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6820",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6594",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7469",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7469",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7506",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7416",,,,,,,"fee schedule","5696","8116",
"Cystoscopy and treatment","52332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8116",,,,,,,"fee schedule","5696","8116",
"Cystouretero & or pyeloscope","52351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19525",,,,,,,"fee schedule","16825","20395",
"Cystouretero & or pyeloscope","52351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20395",,,,,,,"fee schedule","16825","20395",
"Cystouretero & or pyeloscope","52351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20395",,,,,,,"fee schedule","16825","20395",
"Cystouretero & or pyeloscope","52351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17998",,,,,,,"fee schedule","16825","20395",
"Cystouretero & or pyeloscope","52351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16825",,,,,,,"fee schedule","16825","20395",
"Cystouretero & or pyeloscope","52351","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18132",,,,,,,"fee schedule","16825","20395",
"Cystouretero & or pyeloscope","52351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19525",,,,,,,"fee schedule","16825","20395",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7514",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","8116",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6594",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7469",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6820",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5696",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7469",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7506",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9382",,,,,,,"fee schedule","5696","9382",
"Cystouretero w/stone remove","52352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","8116",,,,,,,"fee schedule","5696","9382",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11909",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","8506",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11223",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9614",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9541",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10807",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10807",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10583",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10459",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Lithotripsy","52353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11909",,,,,,,"fee schedule","8506","11909",
"Cystouretero W/Biopsy","52354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","31285",,,,,,,"fee schedule","26959","31862",
"Cystouretero W/Biopsy","52354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","31862",,,,,,,"fee schedule","26959","31862",
"Cystouretero W/Biopsy","52354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","31862",,,,,,,"fee schedule","26959","31862",
"Cystouretero W/Biopsy","52354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","28134",,,,,,,"fee schedule","26959","31862",
"Cystouretero W/Biopsy","52354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","26959",,,,,,,"fee schedule","26959","31862",
"Cystouretero W/Biopsy","52354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","31285",,,,,,,"fee schedule","26959","31862",
"Cysto/uretero w/lithotripsy","52356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","24230",,,,,,,"fee schedule","20879","25307",
"Cysto/uretero w/lithotripsy","52356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","22335",,,,,,,"fee schedule","20879","25307",
"Cysto/uretero w/lithotripsy","52356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","25307",,,,,,,"fee schedule","20879","25307",
"Cysto/uretero w/lithotripsy","52356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","25307",,,,,,,"fee schedule","20879","25307",
"Cysto/uretero w/lithotripsy","52356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","20879",,,,,,,"fee schedule","20879","25307",
"Cysto/uretero w/lithotripsy","52356","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21337",,,,,,,"fee schedule","20879","25307",
"Cysto/uretero w/lithotripsy","52356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","24230",,,,,,,"fee schedule","20879","25307",
"Prostatectomy (TURP)","52601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","24472",,,,,,,"fee schedule","21089","25561",
"Prostatectomy (TURP)","52601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","25561",,,,,,,"fee schedule","21089","25561",
"Prostatectomy (TURP)","52601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","25561",,,,,,,"fee schedule","21089","25561",
"Prostatectomy (TURP)","52601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","22558",,,,,,,"fee schedule","21089","25561",
"Prostatectomy (TURP)","52601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","21089",,,,,,,"fee schedule","21089","25561",
"Prostatectomy (TURP)","52601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","24472",,,,,,,"fee schedule","21089","25561",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6533",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6455",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6532",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6122",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4951",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5699",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6455",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6737",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6660",,,,,,,"fee schedule","4951","6737",
"Circumcision w/regionl block","54150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6533",,,,,,,"fee schedule","4951","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6533",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2174",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3453",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4185",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3695",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4185",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6737",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6122",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3791",,,,,,,"fee schedule","2174","6737",
"Circumcision neonate","54160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6533",,,,,,,"fee schedule","2174","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6533",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5699",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6455",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4951",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6532",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6737",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6455",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6122",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6660",,,,,,,"fee schedule","4951","6737",
"Circum 28 days or older","54161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6533",,,,,,,"fee schedule","4951","6737",
"Revision of penis","54300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19592",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18059",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20464",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20464",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16884",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54300","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18661",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19592",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19592",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20464",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18059",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20464",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","16884",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19592",,,,,,,"fee schedule","16884","20464",
"Revision of penis","54304","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18661",,,,,,,"fee schedule","16884","20464",
"Removal of hydrocele","55040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16494",,,,,,,"fee schedule","14214","17229",
"Removal of hydrocele","55040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15204",,,,,,,"fee schedule","14214","17229",
"Removal of hydrocele","55040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14214",,,,,,,"fee schedule","14214","17229",
"Removal of hydrocele","55040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17229",,,,,,,"fee schedule","14214","17229",
"Removal of hydrocele","55040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17229",,,,,,,"fee schedule","14214","17229",
"Removal of hydrocele","55040","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15710",,,,,,,"fee schedule","14214","17229",
"Removal of hydrocele","55040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16494",,,,,,,"fee schedule","14214","17229",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6533",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6532",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5699",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6455",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6737",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4951",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6455",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6122",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6660",,,,,,,"fee schedule","4951","6737",
"Removal of sperm duct(s)","55250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6533",,,,,,,"fee schedule","4951","6737",
"Revise spermatic cord veins","55530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","19766",,,,,,,"fee schedule","17031","20645",
"Revise spermatic cord veins","55530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17031",,,,,,,"fee schedule","17031","20645",
"Revise spermatic cord veins","55530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18218",,,,,,,"fee schedule","17031","20645",
"Revise spermatic cord veins","55530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20645",,,,,,,"fee schedule","17031","20645",
"Revise spermatic cord veins","55530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20645",,,,,,,"fee schedule","17031","20645",
"Revise spermatic cord veins","55530","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18825",,,,,,,"fee schedule","17031","20645",
"Revise spermatic cord veins","55530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","19766",,,,,,,"fee schedule","17031","20645",
"Biopsy of prostate","55700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13712",,,,,,,"fee schedule","11337","13712",
"Biopsy of prostate","55700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11337",,,,,,,"fee schedule","11337","13712",
"Biopsy of prostate","55700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12839",,,,,,,"fee schedule","11337","13712",
"Biopsy of prostate","55700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12839",,,,,,,"fee schedule","11337","13712",
"Biopsy of prostate","55700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11816",,,,,,,"fee schedule","11337","13712",
"Biopsy of prostate","55700","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13060",,,,,,,"fee schedule","11337","13712",
"Biopsy of prostate","55700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13712",,,,,,,"fee schedule","11337","13712",
"Laparo radical prostatectomy","55866","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","69572",,,,,,,"fee schedule","57619","69572",
"Laparo radical prostatectomy","55866","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","57619",,,,,,,"fee schedule","57619","69572",
"Laparo radical prostatectomy","55866","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","65254",,,,,,,"fee schedule","57619","69572",
"Laparo radical prostatectomy","55866","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","65254",,,,,,,"fee schedule","57619","69572",
"Laparo radical prostatectomy","55866","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","59951",,,,,,,"fee schedule","57619","69572",
"Laparo radical prostatectomy","55866","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","66265",,,,,,,"fee schedule","57619","69572",
"Laparo radical prostatectomy","55866","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","69572",,,,,,,"fee schedule","57619","69572",
"Partial removal of vulva","56620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16548",,,,,,,"fee schedule","14259","17284",
"Partial removal of vulva","56620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17284",,,,,,,"fee schedule","14259","17284",
"Partial removal of vulva","56620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17284",,,,,,,"fee schedule","14259","17284",
"Partial removal of vulva","56620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15253",,,,,,,"fee schedule","14259","17284",
"Partial removal of vulva","56620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14259",,,,,,,"fee schedule","14259","17284",
"Partial removal of vulva","56620","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15761",,,,,,,"fee schedule","14259","17284",
"Partial removal of vulva","56620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16548",,,,,,,"fee schedule","14259","17284",
"Revise/Remove Sling Repair","57287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","20093",,,,,,,"fee schedule","17317","20093",
"Revise/Remove Sling Repair","57287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17596",,,,,,,"fee schedule","17317","20093",
"Revise/Remove Sling Repair","57287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19928",,,,,,,"fee schedule","17317","20093",
"Revise/Remove Sling Repair","57287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19928",,,,,,,"fee schedule","17317","20093",
"Revise/Remove Sling Repair","57287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","17317",,,,,,,"fee schedule","17317","20093",
"Revise/Remove Sling Repair","57287","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19140",,,,,,,"fee schedule","17317","20093",
"Revise/Remove Sling Repair","57287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","20093",,,,,,,"fee schedule","17317","20093",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11926",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","12733",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13134",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9038",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13283",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11721",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13283",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11932",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","12733",,,,,,,"fee schedule","9038","13283",
"Repair bladder defect","57288","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12981",,,,,,,"fee schedule","9038","13283",
"Laparoscopy surg colpopexy","57425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","41455",,,,,,,"fee schedule","35722","43300",
"Laparoscopy surg colpopexy","57425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","38213",,,,,,,"fee schedule","35722","43300",
"Laparoscopy surg colpopexy","57425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","43300",,,,,,,"fee schedule","35722","43300",
"Laparoscopy surg colpopexy","57425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","43300",,,,,,,"fee schedule","35722","43300",
"Laparoscopy surg colpopexy","57425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","35722",,,,,,,"fee schedule","35722","43300",
"Laparoscopy surg colpopexy","57425","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","39484",,,,,,,"fee schedule","35722","43300",
"Laparoscopy surg colpopexy","57425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","41455",,,,,,,"fee schedule","35722","43300",
"Conization of cervix","57520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","15730",,,,,,,"fee schedule","13554","16431",
"Conization of cervix","57520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14499",,,,,,,"fee schedule","13554","16431",
"Conization of cervix","57520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16431",,,,,,,"fee schedule","13554","16431",
"Conization of cervix","57520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16431",,,,,,,"fee schedule","13554","16431",
"Conization of cervix","57520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","13554",,,,,,,"fee schedule","13554","16431",
"Conization of cervix","57520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","15730",,,,,,,"fee schedule","13554","16431",
"Conization of cervix","57520","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14982",,,,,,,"fee schedule","13554","16431",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7160",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6656",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5045",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5978",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5279",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5978",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5356",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","5895",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5825",,,,,,,"fee schedule","5045","7160",
"Conization of cervix","57522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7160",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7160",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5978",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6656",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5045",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5356",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5279",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5978",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","5895",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5921",,,,,,,"fee schedule","5045","7160",
"Dilation and curettage","58120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7160",,,,,,,"fee schedule","5045","7160",
"Vag hyst including t/o","58262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","34008",,,,,,,"fee schedule","27320","34008",
"Vag hyst including t/o","58262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","30940",,,,,,,"fee schedule","27320","34008",
"Vag hyst including t/o","58262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","27320",,,,,,,"fee schedule","27320","34008",
"Vag hyst including t/o","58262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","30940",,,,,,,"fee schedule","27320","34008",
"Vag hyst including t/o","58262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","29304",,,,,,,"fee schedule","27320","34008",
"Vag hyst including t/o","58262","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","32066",,,,,,,"fee schedule","27320","34008",
"Vag hyst including t/o","58262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","34008",,,,,,,"fee schedule","27320","34008",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","901",,,,,,,"fee schedule","727","1006",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","959",,,,,,,"fee schedule","727","1006",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","727",,,,,,,"fee schedule","727","1006",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1006",,,,,,,"fee schedule","727","1006",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","888",,,,,,,"fee schedule","727","1006",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1006",,,,,,,"fee schedule","727","1006",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","795",,,,,,,"fee schedule","727","1006",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","781",,,,,,,"fee schedule","727","1006",
"Remove intrauterine device","58301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","901",,,,,,,"fee schedule","727","1006",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11737",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11926",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9901",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9038",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8740",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9901",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9348",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10289",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10169",,,,,,,"fee schedule","8740","11926",
"Endometr ablate thermal","58353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11737",,,,,,,"fee schedule","8740","11926",
"LSH w/t/o Uterus Above 250 g","58544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","56618",,,,,,,"fee schedule","48788","59137",
"LSH w/t/o Uterus Above 250 g","58544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","59137",,,,,,,"fee schedule","48788","59137",
"LSH w/t/o Uterus Above 250 g","58544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","59137",,,,,,,"fee schedule","48788","59137",
"LSH w/t/o Uterus Above 250 g","58544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","52190",,,,,,,"fee schedule","48788","59137",
"LSH w/t/o Uterus Above 250 g","58544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","48788",,,,,,,"fee schedule","48788","59137",
"LSH w/t/o Uterus Above 250 g","58544","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","53926",,,,,,,"fee schedule","48788","59137",
"LSH w/t/o Uterus Above 250 g","58544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","56618",,,,,,,"fee schedule","48788","59137",
"Laparo-myomectomy complex","58546","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","69072",,,,,,,"fee schedule","59520","72146",
"Laparo-myomectomy complex","58546","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","72146",,,,,,,"fee schedule","59520","72146",
"Laparo-myomectomy complex","58546","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","63668",,,,,,,"fee schedule","59520","72146",
"Laparo-myomectomy complex","58546","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","72146",,,,,,,"fee schedule","59520","72146",
"Laparo-myomectomy complex","58546","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","59520",,,,,,,"fee schedule","59520","72146",
"Laparo-myomectomy complex","58546","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","65788",,,,,,,"fee schedule","59520","72146",
"Laparo-myomectomy complex","58546","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","69072",,,,,,,"fee schedule","59520","72146",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7160",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5789",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6561",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5045",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6656",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6561",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6568",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5967",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6492",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy dx sep proc","58555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7160",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7160",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6656",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5789",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6561",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5045",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6568",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6561",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5967",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6492",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy biopsy","58558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7160",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11737",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9901",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9038",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11926",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8739",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9901",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9217",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10407",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10262",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy lysis","58559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11737",,,,,,,"fee schedule","8739","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11737",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9038",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9255",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10484",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9931",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11926",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10931",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10484",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10807",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy resect septum","58560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11737",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11737",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9038",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9255",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10484",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10931",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11926",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10484",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9931",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10807",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove myoma","58561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11737",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","7160",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5045",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5789",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6561",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6568",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6656",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5967",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6561",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6492",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy remove fb","58562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","7160",,,,,,,"fee schedule","5045","7160",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11737",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9038",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9255",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10484",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","10931",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11926",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10484",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9931",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10807",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy ablation","58563","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11737",,,,,,,"fee schedule","9038","11926",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","12733",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11926",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9038",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13283",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11721",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13283",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11932",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13134",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12981",,,,,,,"fee schedule","9038","13283",
"Hysteroscopy sterilization","58565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","12733",,,,,,,"fee schedule","9038","13283",
"Tlh w/t/o 250 g or less","58571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","42361",,,,,,,"fee schedule","36502","44246",
"Tlh w/t/o 250 g or less","58571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","44246",,,,,,,"fee schedule","36502","44246",
"Tlh w/t/o 250 g or less","58571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","36502",,,,,,,"fee schedule","36502","44246",
"Tlh w/t/o 250 g or less","58571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","39047",,,,,,,"fee schedule","36502","44246",
"Tlh w/t/o 250 g or less","58571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","44246",,,,,,,"fee schedule","36502","44246",
"Tlh w/t/o 250 g or less","58571","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37248",,,,,,,"fee schedule","36502","44246",
"Tlh w/t/o 250 g or less","58571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","42361",,,,,,,"fee schedule","36502","44246",
"Tlh w/t/o uterus over 250 g","58573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","45407",,,,,,,"fee schedule","39127","47427",
"Tlh w/t/o uterus over 250 g","58573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","41853",,,,,,,"fee schedule","39127","47427",
"Tlh w/t/o uterus over 250 g","58573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","47427",,,,,,,"fee schedule","39127","47427",
"Tlh w/t/o uterus over 250 g","58573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","47427",,,,,,,"fee schedule","39127","47427",
"Tlh w/t/o uterus over 250 g","58573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","39127",,,,,,,"fee schedule","39127","47427",
"Tlh w/t/o uterus over 250 g","58573","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","41332",,,,,,,"fee schedule","39127","47427",
"Tlh w/t/o uterus over 250 g","58573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","45407",,,,,,,"fee schedule","39127","47427",
"Laparoscopy lysis","58660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","31901",,,,,,,"fee schedule","27490","33322",
"Laparoscopy lysis","58660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","29406",,,,,,,"fee schedule","27490","33322",
"Laparoscopy lysis","58660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","27490",,,,,,,"fee schedule","27490","33322",
"Laparoscopy lysis","58660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","33322",,,,,,,"fee schedule","27490","33322",
"Laparoscopy lysis","58660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","33322",,,,,,,"fee schedule","27490","33322",
"Laparoscopy lysis","58660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","31901",,,,,,,"fee schedule","27490","33322",
"Laparoscopy remove adnexa","58661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","25814",,,,,,,"fee schedule","22244","26962",
"Laparoscopy remove adnexa","58661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","23794",,,,,,,"fee schedule","22244","26962",
"Laparoscopy remove adnexa","58661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","26962",,,,,,,"fee schedule","22244","26962",
"Laparoscopy remove adnexa","58661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","26962",,,,,,,"fee schedule","22244","26962",
"Laparoscopy remove adnexa","58661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","22244",,,,,,,"fee schedule","22244","26962",
"Laparoscopy remove adnexa","58661","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","25389",,,,,,,"fee schedule","22244","26962",
"Laparoscopy remove adnexa","58661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","25814",,,,,,,"fee schedule","22244","26962",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13708",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11983",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13579",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13579",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12454",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13549",,,,,,,"fee schedule","10324","13708",
"Laparoscopy excise lesions","58662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13708",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11983",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13579",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13579",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12454",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13549",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal cautery","58670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13622",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","13289",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","13708",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11983",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13579",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10324",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13579",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12454",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13549",,,,,,,"fee schedule","10324","13708",
"Laparoscopy tubal block","58671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","13289",,,,,,,"fee schedule","10324","13708",
"Removal of ovarian cyst(s)","58925","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","33903",,,,,,,"fee schedule","27320","33903",
"Removal of ovarian cyst(s)","58925","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","29215",,,,,,,"fee schedule","27320","33903",
"Removal of ovarian cyst(s)","58925","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","30940",,,,,,,"fee schedule","27320","33903",
"Removal of ovarian cyst(s)","58925","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","27320",,,,,,,"fee schedule","27320","33903",
"Removal of ovarian cyst(s)","58925","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","30940",,,,,,,"fee schedule","27320","33903",
"Removal of ovarian cyst(s)","58925","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","32291",,,,,,,"fee schedule","27320","33903",
"Removal of ovarian cyst(s)","58925","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","33903",,,,,,,"fee schedule","27320","33903",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1782",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1332",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1724",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1757",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1605",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1724",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1521",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1809",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1782",,,,,,,"fee schedule","1332","1809",
"Retrieval of oocyte","58970","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1796",,,,,,,"fee schedule","1332","1809",
"Treat ectopic pregnancy","59151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","38681",,,,,,,"fee schedule","32289","38681",
"Treat ectopic pregnancy","59151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","36568",,,,,,,"fee schedule","32289","38681",
"Treat ectopic pregnancy","59151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","33332",,,,,,,"fee schedule","32289","38681",
"Treat ectopic pregnancy","59151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","36568",,,,,,,"fee schedule","32289","38681",
"Treat ectopic pregnancy","59151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","32289",,,,,,,"fee schedule","32289","38681",
"Treat ectopic pregnancy","59151","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","36842",,,,,,,"fee schedule","32289","38681",
"Treat ectopic pregnancy","59151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","38681",,,,,,,"fee schedule","32289","38681",
"Care of miscarriage","59820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11157",,,,,,,"fee schedule","9613","11653",
"Care of miscarriage","59820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11653",,,,,,,"fee schedule","9613","11653",
"Care of miscarriage","59820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10283",,,,,,,"fee schedule","9613","11653",
"Care of miscarriage","59820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11653",,,,,,,"fee schedule","9613","11653",
"Care of miscarriage","59820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9613",,,,,,,"fee schedule","9613","11653",
"Care of miscarriage","59820","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10624",,,,,,,"fee schedule","9613","11653",
"Care of miscarriage","59820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11157",,,,,,,"fee schedule","9613","11653",
"Treatment of miscarriage","59821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","16470",,,,,,,"fee schedule","14192","17204",
"Treatment of miscarriage","59821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17204",,,,,,,"fee schedule","14192","17204",
"Treatment of miscarriage","59821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15181",,,,,,,"fee schedule","14192","17204",
"Treatment of miscarriage","59821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","14192",,,,,,,"fee schedule","14192","17204",
"Treatment of miscarriage","59821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17204",,,,,,,"fee schedule","14192","17204",
"Treatment of miscarriage","59821","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15687",,,,,,,"fee schedule","14192","17204",
"Treatment of miscarriage","59821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","16470",,,,,,,"fee schedule","14192","17204",
"Remove cerclage suture","59871","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","11279",,,,,,,"fee schedule","9718","11780",
"Remove cerclage suture","59871","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","9718",,,,,,,"fee schedule","9718","11780",
"Remove cerclage suture","59871","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10396",,,,,,,"fee schedule","9718","11780",
"Remove cerclage suture","59871","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11780",,,,,,,"fee schedule","9718","11780",
"Remove cerclage suture","59871","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11780",,,,,,,"fee schedule","9718","11780",
"Remove cerclage suture","59871","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10740",,,,,,,"fee schedule","9718","11780",
"Remove cerclage suture","59871","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","11279",,,,,,,"fee schedule","9718","11780",
"Partial removal of thyroid","60220","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","34525",,,,,,,"fee schedule","29751","36061",
"Partial removal of thyroid","60220","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","36061",,,,,,,"fee schedule","29751","36061",
"Partial removal of thyroid","60220","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","36061",,,,,,,"fee schedule","29751","36061",
"Partial removal of thyroid","60220","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","31823",,,,,,,"fee schedule","29751","36061",
"Partial removal of thyroid","60220","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","29751",,,,,,,"fee schedule","29751","36061",
"Partial removal of thyroid","60220","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","34525",,,,,,,"fee schedule","29751","36061",
"Partial removal of thyroid","60220","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","32883",,,,,,,"fee schedule","29751","36061",
"Removal of thyroid","60240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","38799",,,,,,,"fee schedule","32289","38799",
"Removal of thyroid","60240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","33434",,,,,,,"fee schedule","32289","38799",
"Removal of thyroid","60240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","36568",,,,,,,"fee schedule","32289","38799",
"Removal of thyroid","60240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","36568",,,,,,,"fee schedule","32289","38799",
"Removal of thyroid","60240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","32289",,,,,,,"fee schedule","32289","38799",
"Removal of thyroid","60240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","38799",,,,,,,"fee schedule","32289","38799",
"Explore parathyroid glands","60500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","31489",,,,,,,"fee schedule","27134","32890",
"Explore parathyroid glands","60500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","29025",,,,,,,"fee schedule","27134","32890",
"Explore parathyroid glands","60500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","32890",,,,,,,"fee schedule","27134","32890",
"Explore parathyroid glands","60500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","32890",,,,,,,"fee schedule","27134","32890",
"Explore parathyroid glands","60500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","27134",,,,,,,"fee schedule","27134","32890",
"Explore parathyroid glands","60500","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","29992",,,,,,,"fee schedule","27134","32890",
"Explore parathyroid glands","60500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","31489",,,,,,,"fee schedule","27134","32890",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2199",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2491",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2491",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2135",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1941",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2110",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3833",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4341",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4341",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4260",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4709",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar crv/thrc","62321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","4709",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2199",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2491",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2491",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1941",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2135",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2110",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","2491",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3833",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4341",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4341",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4134",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62323","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4570",,,,,,,"fee schedule","1836","4570",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3570",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2199",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2491",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2491",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3346",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3682",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2655",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3570",,,,,,,"fee schedule","1836","3682",
"Njx interlaminar lmbr/sac","62327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3570",,,,,,,"fee schedule","1836","3570",
"Njx interlaminar lmbr/sac","62327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","3570",
"Njx interlaminar lmbr/sac","62327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","3570",
"Njx interlaminar lmbr/sac","62327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3570",,,,,,,"fee schedule","1836","3570",
"Low back disk surgery","63030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","30103",,,,,,,"fee schedule","25939","31441",
"Low back disk surgery","63030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","27747",,,,,,,"fee schedule","25939","31441",
"Low back disk surgery","63030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","31441",,,,,,,"fee schedule","25939","31441",
"Low back disk surgery","63030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","31441",,,,,,,"fee schedule","25939","31441",
"Low back disk surgery","63030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","25939",,,,,,,"fee schedule","25939","31441",
"Low back disk surgery","63030","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","28671",,,,,,,"fee schedule","25939","31441",
"Low back disk surgery","63030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","30103",,,,,,,"fee schedule","25939","31441",
"Laminotomy single lumbar","63042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","39370",,,,,,,"fee schedule","33925","41121",
"Laminotomy single lumbar","63042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36290",,,,,,,"fee schedule","33925","41121",
"Laminotomy single lumbar","63042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41121",,,,,,,"fee schedule","33925","41121",
"Laminotomy single lumbar","63042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41121",,,,,,,"fee schedule","33925","41121",
"Laminotomy single lumbar","63042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","33925",,,,,,,"fee schedule","33925","41121",
"Laminotomy single lumbar","63042","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37498",,,,,,,"fee schedule","33925","41121",
"Laminotomy single lumbar","63042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","39370",,,,,,,"fee schedule","33925","41121",
"Remove spine lamina 1 lmbr","63047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","32061",,,,,,,"fee schedule","27628","33488",
"Remove spine lamina 1 lmbr","63047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","33488",,,,,,,"fee schedule","27628","33488",
"Remove spine lamina 1 lmbr","63047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","29554",,,,,,,"fee schedule","27628","33488",
"Remove spine lamina 1 lmbr","63047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","33488",,,,,,,"fee schedule","27628","33488",
"Remove spine lamina 1 lmbr","63047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","27628",,,,,,,"fee schedule","27628","33488",
"Remove spine lamina 1 lmbr","63047","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","30538",,,,,,,"fee schedule","27628","33488",
"Remove spine lamina 1 lmbr","63047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","32061",,,,,,,"fee schedule","27628","33488",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1941",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2199",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2491",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2491",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2135",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2110",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural c/t","64479","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1080",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","747",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","986",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1026",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1013",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1112",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1026",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","907",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1099",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1080",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1941",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2199",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2491",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2491",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2135",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2110",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural l/s","64483","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","2491",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1080",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","986",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","747",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1013",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1026",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1112",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1026",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","907",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1080",,,,,,,"fee schedule","747","1112",
"Inj foramen epidural add-on","64484","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1099",,,,,,,"fee schedule","747","1112",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2199",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2491",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2491",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2071",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2135",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2110",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 1 lev","64490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","959",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","901",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","727",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1006",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","888",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1006",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","795",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","913",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 2 lev","64491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","901",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","901",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","959",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","727",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","888",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1006",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1006",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","795",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","913",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt c/t 3 lev","64492","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","901",,,,,,,"fee schedule","727","1006",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2199",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2491",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2491",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2135",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2071",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","2491",
"Inj paravert f jnt l/s 1 lev","64493","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2110",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2070",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1836",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2425",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1941",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2135",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2199",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2491",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2491",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2110",,,,,,,"fee schedule","1836","2491",
"N block lumbar/thoracic","64520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2070",,,,,,,"fee schedule","1836","2491",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5226",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4988",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4543",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3779",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5147",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5147",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","5389",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4896",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5327",,,,,,,"fee schedule","3779","5389",
"Revise ulnar nerve at elbow","64718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5226",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5226",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4988",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5147",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5147",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3779",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","5389",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4543",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4896",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5327",,,,,,,"fee schedule","3779","5389",
"Carpal tunnel surgery","64721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5226",,,,,,,"fee schedule","3779","5389",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6445",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5532",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4194",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6039",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5745",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6507",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6507",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6647",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6570",,,,,,,"fee schedule","4194","6647",
"Removal of eye lesion","65426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6445",,,,,,,"fee schedule","4194","6647",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1213",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1601",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1498",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1407",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1593",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1593",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1403",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1545",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1529",,,,,,,"fee schedule","1213","1601",
"After cataract laser surgery","66821","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1498",,,,,,,"fee schedule","1213","1601",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6611",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4788",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6319",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5802",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6573",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6573",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6193",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6820",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6611",,,,,,,"fee schedule","4788","6820",
"Cataract surgery complex","66982","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6737",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6611",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4788",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6319",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5802",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6573",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6573",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6193",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6820",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6737",,,,,,,"fee schedule","4788","6820",
"Cataract surg w/iol 1 stage","66984","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6611",,,,,,,"fee schedule","4788","6820",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5532",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6889",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6396",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4194",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7106",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7245",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7245",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6455",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7023",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6889",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5532",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","6889",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7245",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4194",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7245",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6396",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6455",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","7106",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7023",,,,,,,"fee schedule","4194","7245",
"Revise eye muscle","67314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","6889",,,,,,,"fee schedule","4194","7245",
"Repair eyelid defect","67904","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","14440",,,,,,,"fee schedule","12444","15083",
"Repair eyelid defect","67904","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","12444",,,,,,,"fee schedule","12444","15083",
"Repair eyelid defect","67904","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13311",,,,,,,"fee schedule","12444","15083",
"Repair eyelid defect","67904","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15083",,,,,,,"fee schedule","12444","15083",
"Repair eyelid defect","67904","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15083",,,,,,,"fee schedule","12444","15083",
"Repair eyelid defect","67904","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","14440",,,,,,,"fee schedule","12444","15083",
"Repair eyelid defect","67904","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13754",,,,,,,"fee schedule","12444","15083",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5437",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5532",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4194",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","5610",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5394",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5394",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4762",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5097",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5544",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5437",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5437",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5394",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5532",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","5610",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4194",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4762",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5394",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5097",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5544",,,,,,,"fee schedule","4194","5610",
"Probe nasolacrimal duct","68815","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5437",,,,,,,"fee schedule","4194","5610",
"Rebuild outer ear canal","69310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","32682",,,,,,,"fee schedule","28162","34137",
"Rebuild outer ear canal","69310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","30127",,,,,,,"fee schedule","28162","34137",
"Rebuild outer ear canal","69310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","34137",,,,,,,"fee schedule","28162","34137",
"Rebuild outer ear canal","69310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","34137",,,,,,,"fee schedule","28162","34137",
"Rebuild outer ear canal","69310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","28162",,,,,,,"fee schedule","28162","34137",
"Rebuild outer ear canal","69310","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","31129",,,,,,,"fee schedule","28162","34137",
"Rebuild outer ear canal","69310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","32682",,,,,,,"fee schedule","28162","34137",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4672",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4570",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4532",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4532",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3462",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4001",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4379",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4822",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4765",,,,,,,"fee schedule","3462","4822",
"Create eardrum opening","69436","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4672",,,,,,,"fee schedule","3462","4822",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","12508",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11706",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13261",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","12904",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10191",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","13447",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13261",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","11723",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12754",,,,,,,"fee schedule","10191","13447",
"Repair eardrum structures","69631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","12508",,,,,,,"fee schedule","10191","13447",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1236",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1097",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","936",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1064",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1064",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","835",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1092",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1410",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1085",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o dye","70450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1097",,,,,,,"fee schedule","835","1410",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1710",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1460",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1298",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1927",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1700",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2194",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1658",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1658",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1690",,,,,,,"fee schedule","1298","2194",
"Ct head/brain w/o & w/dye","70470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1710",,,,,,,"fee schedule","1298","2194",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1488",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1273",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1680",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1130",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1441",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1441",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1480",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1915",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1471",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/o dye","70480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1488",,,,,,,"fee schedule","1130","1915",
"Ct orbit/ear/fossa w/dye","70481","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4671",,,,,,,"fee schedule","4671","4671",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1304",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1471",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1115",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","988",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1256",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1256",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1293",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1675",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1284",,,,,,,"fee schedule","988","1675",
"Ct maxillofacial w/o dye","70486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1304",,,,,,,"fee schedule","988","1675",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1548",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1746",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1323",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1174",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1994",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1499",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1499",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1539",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1530",,,,,,,"fee schedule","1174","1994",
"Ct soft tissue neck w/dye","70491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1548",,,,,,,"fee schedule","1174","1994",
"Ct angiography head","70496","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3752",,,,,,,"fee schedule","3752","5012",
"Ct angiography head","70496","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4446",,,,,,,"fee schedule","3752","5012",
"Ct angiography head","70496","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5012",,,,,,,"fee schedule","3752","5012",
"Ct angiography head","70496","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3934",,,,,,,"fee schedule","3752","5012",
"Ct angiography head","70496","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5012",,,,,,,"fee schedule","3752","5012",
"Ct angiography head","70496","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4865",,,,,,,"fee schedule","3752","5012",
"Ct angiography head","70496","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3752",,,,,,,"fee schedule","3752","5012",
"Ct angiography neck","70498","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3757",,,,,,,"fee schedule","3757","5019",
"Ct angiography neck","70498","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3941",,,,,,,"fee schedule","3757","5019",
"Ct angiography neck","70498","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5019",,,,,,,"fee schedule","3757","5019",
"Ct angiography neck","70498","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4452",,,,,,,"fee schedule","3757","5019",
"Ct angiography neck","70498","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5019",,,,,,,"fee schedule","3757","5019",
"Ct angiography neck","70498","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3757",,,,,,,"fee schedule","3757","5019",
"Ct angiography neck","70498","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4870",,,,,,,"fee schedule","3757","5019",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5654",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5008",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4845",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4845",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4980",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4284",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3801",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6450",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4947",,,,,,,"fee schedule","3801","6450",
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5008",,,,,,,"fee schedule","3801","6450",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3117",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3016",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3517",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2368",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3016",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2665",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3099",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","4009",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3081",,,,,,,"fee schedule","2368","4009",
"Mr Angiography Head W/O Dye","70544","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3117",,,,,,,"fee schedule","2368","4009",
"Mr angiograph neck w/o&w/dye","70549","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6608",,,,,,,"fee schedule","6608","6608",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2948",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2517",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2235",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3322",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2930",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2852",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2852",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3788",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2909",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o dye","70551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2948",,,,,,,"fee schedule","2235","3788",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4987",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5608",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4826",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4249",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4960",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4826",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3786",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6382",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4923",,,,,,,"fee schedule","3786","6382",
"Mri brain stem w/o & w/dye","70553","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4987",,,,,,,"fee schedule","3786","6382",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1408",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1582",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1065",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1200",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1362",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1362",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1401",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1804",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1389",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/o dye","71250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1408",,,,,,,"fee schedule","1065","1804",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1722",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1469",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2207",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1936",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1664",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1305",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1664",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1710",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1699",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/dye","71260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1722",,,,,,,"fee schedule","1305","2207",
"Ct thorax w/o & w/dye","71270","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5030",,,,,,,"fee schedule","5030","5030",
"Ct angiography chest","71275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3918",,,,,,,"fee schedule","3918","5235",
"Ct angiography chest","71275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4642",,,,,,,"fee schedule","3918","5235",
"Ct angiography chest","71275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5235",,,,,,,"fee schedule","3918","5235",
"Ct angiography chest","71275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4109",,,,,,,"fee schedule","3918","5235",
"Ct angiography chest","71275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5235",,,,,,,"fee schedule","3918","5235",
"Ct angiography chest","71275","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5080",,,,,,,"fee schedule","3918","5235",
"Ct angiography chest","71275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3918",,,,,,,"fee schedule","3918","5235",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1584",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1410",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1201",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1365",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1365",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1068",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1402",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1807",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1391",,,,,,,"fee schedule","1068","1807",
"Ct neck spine w/o dye","72125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1410",,,,,,,"fee schedule","1068","1807",
"Ct chest spine w/o dye","72128","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3873",,,,,,,"fee schedule","3873","3873",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1403",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1199",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1581",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1396",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1803",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1065",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1360",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1360",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1387",,,,,,,"fee schedule","1065","1803",
"Ct lumbar spine w/o dye","72131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1403",,,,,,,"fee schedule","1065","1803",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2717",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2319",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2060",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3059",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2703",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2629",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2629",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3486",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2684",,,,,,,"fee schedule","2060","3486",
"Mri neck spine w/o dye","72141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2717",,,,,,,"fee schedule","2060","3486",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2868",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3228",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2448",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3679",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2175",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2777",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2777",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2852",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2829",,,,,,,"fee schedule","2175","3679",
"Mri chest spine w/o dye","72146","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2868",,,,,,,"fee schedule","2175","3679",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2864",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3227",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3676",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2447",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2173",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2772",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2772",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2849",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2828",,,,,,,"fee schedule","2173","3676",
"Mri lumbar spine w/o dye","72148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2864",,,,,,,"fee schedule","2173","3676",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4947",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4215",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5560",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3754",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4785",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4785",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4918",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6328",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4884",,,,,,,"fee schedule","3754","6328",
"Mri neck spine w/o & w/dye","72156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4947",,,,,,,"fee schedule","3754","6328",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4058",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4766",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3615",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5354",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6096",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4610",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4610",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4735",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4705",,,,,,,"fee schedule","3615","6096",
"Mri chest spine w/o & w/dye","72157","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4766",,,,,,,"fee schedule","3615","6096",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4943",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4212",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3754",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5557",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4782",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4782",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4916",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6326",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4882",,,,,,,"fee schedule","3754","6326",
"Mri lumbar spine w/o & w/dye","72158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4943",,,,,,,"fee schedule","3754","6326",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1362",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1530",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1159",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1355",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1744",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1034",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1321",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1321",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1343",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/o dye","72192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1362",,,,,,,"fee schedule","1034","1744",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1643",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1247",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1403",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1850",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1635",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2107",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1590",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1590",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1624",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/dye","72193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1643",,,,,,,"fee schedule","1247","2107",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2134",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1823",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2404",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2065",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2065",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1622",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2122",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2743",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2107",,,,,,,"fee schedule","1622","2743",
"Ct pelvis w/o & w/dye","72194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2134",,,,,,,"fee schedule","1622","2743",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2507",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2927",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2831",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2223",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2831",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3307",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2912",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3771",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2891",,,,,,,"fee schedule","2223","3771",
"Mri Pelvis W/O Dye","72195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2927",,,,,,,"fee schedule","2223","3771",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5685",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5039",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5010",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4308",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4874",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3825",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4874",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6479",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4972",,,,,,,"fee schedule","3825","6479",
"Mri pelvis w/o & w/dye","72197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5039",,,,,,,"fee schedule","3825","6479",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1100",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1284",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1450",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1243",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1243",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","978",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1280",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1653",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1284",,,,,,,"fee schedule","978","1653",
"Ct upper extremity w/o dye","73200","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1271",,,,,,,"fee schedule","978","1653",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2951",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2529",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2932",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3336",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2853",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2853",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2236",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3805",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2910",,,,,,,"fee schedule","2236","3805",
"Mri Upper Extremity W/O Dye","73218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2951",,,,,,,"fee schedule","2236","3805",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2417",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2823",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3191",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2808",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3643",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2733",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2143",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2733",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2788",,,,,,,"fee schedule","2143","3643",
"Mri joint upr extrem w/o dye","73221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2823",,,,,,,"fee schedule","2143","3643",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1450",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1100",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1284",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1243",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1243",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","978",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1280",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1653",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1271",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/o dye","73700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1284",,,,,,,"fee schedule","978","1653",
"Ct lower extremity w/dye","73701","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6080",,,,,,,"fee schedule","6080","6080",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2905",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2491",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2205",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2813",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3285",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2813",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2891",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3751",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2870",,,,,,,"fee schedule","2205","3751",
"Mri Lower Extremity W/O Dye","73718","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2905",,,,,,,"fee schedule","2205","3751",
"Mri lwr extremity w/o&w/dye","73720","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7913",,,,,,,"fee schedule","7913","7913",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2862",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3231",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2766",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2766",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2450",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2170",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2847",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3689",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2862",,,,,,,"fee schedule","2170","3689",
"Mri jnt of lwr extre w/o dye","73721","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2824",,,,,,,"fee schedule","2170","3689",
"Mri joint lwr extr w/o&w/dye","73723","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9246",,,,,,,"fee schedule","9246","9246",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1330",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1136",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1499",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1322",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1706",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1008",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1287",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1287",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1314",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/o dye","74150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1330",,,,,,,"fee schedule","1008","1706",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1526",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2012",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","1784",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1729",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1729",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1357",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","1773",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","2294",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1763",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/dye","74160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","1784",,,,,,,"fee schedule","1357","2294",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2359",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","2018",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2282",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2662",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1790",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2282",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2345",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3036",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2330",,,,,,,"fee schedule","1790","3036",
"Ct abdomen w/o & w/dye","74170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2359",,,,,,,"fee schedule","1790","3036",
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5560",,,,,,,"fee schedule","5560","7425",
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5828",,,,,,,"fee schedule","5560","7425",
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7425",,,,,,,"fee schedule","5560","7425",
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7425",,,,,,,"fee schedule","5560","7425",
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","6586",,,,,,,"fee schedule","5560","7425",
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7206",,,,,,,"fee schedule","5560","7425",
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5560",,,,,,,"fee schedule","5560","7425",
"Ct abd & pelvis w/o contrast","74176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3871",,,,,,,"fee schedule","3871","5169",
"Ct abd & pelvis w/o contrast","74176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4057",,,,,,,"fee schedule","3871","5169",
"Ct abd & pelvis w/o contrast","74176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5169",,,,,,,"fee schedule","3871","5169",
"Ct abd & pelvis w/o contrast","74176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5169",,,,,,,"fee schedule","3871","5169",
"Ct abd & pelvis w/o contrast","74176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4585",,,,,,,"fee schedule","3871","5169",
"Ct abd & pelvis w/o contrast","74176","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5017",,,,,,,"fee schedule","3871","5169",
"Ct abd & pelvis w/o contrast","74176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3871",,,,,,,"fee schedule","3871","5169",
"Ct abd & pelv w/contrast","74177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","4717",,,,,,,"fee schedule","4717","6302",
"Ct abd & pelv w/contrast","74177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6302",,,,,,,"fee schedule","4717","6302",
"Ct abd & pelv w/contrast","74177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6302",,,,,,,"fee schedule","4717","6302",
"Ct abd & pelv w/contrast","74177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4948",,,,,,,"fee schedule","4717","6302",
"Ct abd & pelv w/contrast","74177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5590",,,,,,,"fee schedule","4717","6302",
"Ct abd & pelv w/contrast","74177","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6117",,,,,,,"fee schedule","4717","6302",
"Ct abd & pelv w/contrast","74177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","4717",,,,,,,"fee schedule","4717","6302",
"Ct abd & pelv 1/> regns","74178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5023",,,,,,,"fee schedule","5023","6709",
"Ct abd & pelv 1/> regns","74178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5267",,,,,,,"fee schedule","5023","6709",
"Ct abd & pelv 1/> regns","74178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6709",,,,,,,"fee schedule","5023","6709",
"Ct abd & pelv 1/> regns","74178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6709",,,,,,,"fee schedule","5023","6709",
"Ct abd & pelv 1/> regns","74178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5952",,,,,,,"fee schedule","5023","6709",
"Ct abd & pelv 1/> regns","74178","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6512",,,,,,,"fee schedule","5023","6709",
"Ct abd & pelv 1/> regns","74178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5023",,,,,,,"fee schedule","5023","6709",
"Mri abdomen w/o dye","74181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","3192",,,,,,,"fee schedule","3192","4263",
"Mri abdomen w/o dye","74181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4263",,,,,,,"fee schedule","3192","4263",
"Mri abdomen w/o dye","74181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4263",,,,,,,"fee schedule","3192","4263",
"Mri abdomen w/o dye","74181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3782",,,,,,,"fee schedule","3192","4263",
"Mri abdomen w/o dye","74181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3347",,,,,,,"fee schedule","3192","4263",
"Mri abdomen w/o dye","74181","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4139",,,,,,,"fee schedule","3192","4263",
"Mri abdomen w/o dye","74181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","3192",,,,,,,"fee schedule","3192","4263",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5041",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4311",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5688",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4876",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4876",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3826",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5014",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6487",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4974",,,,,,,"fee schedule","3826","6487",
"Mri abdomen w/o & w/dye","74183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5041",,,,,,,"fee schedule","3826","6487",
"Cardiac mri for morph w/dye","75561","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5264",,,,,,,"fee schedule","5264","5264",
"Ct hrt w/o dye w/ca test","75571","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","545",,,,,,,"fee schedule","545","545",
"Ct hrt w/3d image","75572","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3850",,,,,,,"fee schedule","3850","3850",
"Ct angio hrt w/3d image","75574","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2357",,,,,,,"fee schedule","2357","3148",
"Ct angio hrt w/3d image","75574","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3148",,,,,,,"fee schedule","2357","3148",
"Ct angio hrt w/3d image","75574","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3148",,,,,,,"fee schedule","2357","3148",
"Ct angio hrt w/3d image","75574","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","2793",,,,,,,"fee schedule","2357","3148",
"Ct angio hrt w/3d image","75574","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2470",,,,,,,"fee schedule","2357","3148",
"Ct angio hrt w/3d image","75574","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3056",,,,,,,"fee schedule","2357","3148",
"Ct angio hrt w/3d image","75574","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2357",,,,,,,"fee schedule","2357","3148",
"3d render w/intrp postproces","76376","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1134",,,,,,,"fee schedule","1134","1134",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","922",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","789",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1041",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","702",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","895",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1189",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","895",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","916",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","908",,,,,,,"fee schedule","702","1189",
"CAT scan follow-up study","76380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","922",,,,,,,"fee schedule","702","1189",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","837",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","947",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","636",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","718",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","810",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","810",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","834",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","1079",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","827",,,,,,,"fee schedule","636","1079",
"CT Scan for Therapy Guide","77014","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","837",,,,,,,"fee schedule","636","1079",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5294",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5958",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","4059",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6790",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4515",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4019",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5123",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5123",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5174",,,,,,,"fee schedule","4019","6790",
"Mri breast c- bilateral","77047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5294",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5294",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4515",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4019",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5958",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5123",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5123",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5263",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","6790",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5227",,,,,,,"fee schedule","4019","6790",
"Mri breast c-+ w/cad bi","77049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5294",,,,,,,"fee schedule","4019","6790",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4358",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","5555",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5752",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4278",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","5521",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","9251",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5452",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5452",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5947",,,,,,,"fee schedule","4278","9251",
"Pet image full body","78813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","5555",,,,,,,"fee schedule","4278","9251",
"Pet image w/ct skull-thigh","78815","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8629",,,,,,,"fee schedule","8629","8629",
"Pet image w/ct full body","78816","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9373",,,,,,,"fee schedule","9373","9373",
"Human ig im","90281","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","178.8",,,,,,,"fee schedule","178.8","178.8",
"Human ig iv","90283","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","436.95",,,,,,,"fee schedule","436.95","436.95",
"Human ig sc","90284","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","57.56",,,,,,,"fee schedule","57.56","57.56",
"Cmv ig iv","90291","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5745.52",,,,,,,"fee schedule","5745.52","5745.52",
"Diphtheria antitoxin","90296","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10027.9",,,,,,,"fee schedule","10027.9","10027.9",
"Hep b ig im","90371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","329.39",,,,,,,"fee schedule","329.39","399.49",
"Hep b ig im","90371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","329.39",,,,,,,"fee schedule","329.39","399.49",
"Hep b ig im","90371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","329.39",,,,,,,"fee schedule","329.39","399.49",
"Hep b ig im","90371","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","399.49",,,,,,,"fee schedule","329.39","399.49",
"Rabies ig im/sc","90375","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","666.8",,,,,,,"fee schedule","666.8","1157.74",
"Rabies ig im/sc","90375","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","666.8",,,,,,,"fee schedule","666.8","1157.74",
"Rabies ig im/sc","90375","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","666.8",,,,,,,"fee schedule","666.8","1157.74",
"Rabies ig im/sc","90375","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1157.74",,,,,,,"fee schedule","666.8","1157.74",
"Rabies ig heat treated","90376","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","768.93",,,,,,,"fee schedule","768.93","768.93",
"Rabies ig ht&sol human im/sc","90377","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","554.64",,,,,,,"fee schedule","554.64","554.64",
"Rabies ig ht&sol human im/sc","90377","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","554.64",,,,,,,"fee schedule","554.64","554.64",
"Rabies ig ht&sol human im/sc","90377","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","554.64",,,,,,,"fee schedule","554.64","554.64",
"Rsv mab im 50mg","90378","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6233.81",,,,,,,"fee schedule","6233.81","6233.81",
"Rh ig full-dose im","90384","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","385.86",,,,,,,"fee schedule","385.86","385.86",
"Rh ig minidose im","90385","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","203.55",,,,,,,"fee schedule","203.55","203.55",
"Rh ig iv","90386","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2103.46",,,,,,,"fee schedule","2103.46","2103.46",
"Tetanus ig im","90389","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2263.67",,,,,,,"fee schedule","2263.67","2263.67",
"Varicella-zoster ig im","90396","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5781.67",,,,,,,"fee schedule","5781.67","5781.67",
"Immune globulin","90399","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","75.39",,,,,,,"fee schedule","75.39","75.39",
"Anthrax vaccine sc or im","90581","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","346.24",,,,,,,"fee schedule","346.24","346.24",
"Bcg vaccine percut","90585","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","639.02",,,,,,,"fee schedule","639.02","639.02",
"Bcg vaccine intravesical","90586","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","361.01",,,,,,,"fee schedule","361.01","475.79",
"Bcg vaccine intravesical","90586","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","361.01",,,,,,,"fee schedule","361.01","475.79",
"Bcg vaccine intravesical","90586","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","361.01",,,,,,,"fee schedule","361.01","475.79",
"Bcg vaccine intravesical","90586","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","475.79",,,,,,,"fee schedule","361.01","475.79",
"Menb rp w/omv vaccine im","90620","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","728.83",,,,,,,"fee schedule","728.83","728.83",
"Menb rlp vaccine im","90621","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","609.31",,,,,,,"fee schedule","609.31","609.31",
"Hepa vaccine adult im","90632","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","165.96",,,,,,,"fee schedule","165.96","203.16",
"Hepa vaccine adult im","90632","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","165.96",,,,,,,"fee schedule","165.96","203.16",
"Hepa vaccine adult im","90632","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","165.96",,,,,,,"fee schedule","165.96","203.16",
"Hepa vaccine adult im","90632","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","203.16",,,,,,,"fee schedule","165.96","203.16",
"Hepa vacc ped/adol 2 dose im","90633","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","131.43",,,,,,,"fee schedule","131.43","131.43",
"Hepa vacc ped/adol 3 dose","90634","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","86.87",,,,,,,"fee schedule","86.87","86.87",
"Hep a/hep b vacc adult im","90636","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","403.72",,,,,,,"fee schedule","403.72","403.72",
"Hib-mency vacc 6wk-18m0 im","90644","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","66.09",,,,,,,"fee schedule","66.09","66.09",
"Hib prp-omp vacc 3 dose im","90647","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","106.21",,,,,,,"fee schedule","106.21","106.21",
"Hib prp-t vaccine 4 dose im","90648","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","57.07",,,,,,,"fee schedule","57.07","57.07",
"4vhpv vaccine 3 dose im","90649","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","315.68",,,,,,,"fee schedule","315.68","315.68",
"9vhpv vaccine 3 dose im","90651","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","926.82",,,,,,,"fee schedule","926.82","926.82",
"Iiv adjuvant vaccine im","90653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","192.03",,,,,,,"fee schedule","192.03","201.82",
"Iiv adjuvant vaccine im","90653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","192.03",,,,,,,"fee schedule","192.03","201.82",
"Iiv adjuvant vaccine im","90653","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","192.03",,,,,,,"fee schedule","192.03","201.82",
"Iiv adjuvant vaccine im","90653","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","201.82",,,,,,,"fee schedule","192.03","201.82",
"Iiv3 vacc no prsv 0.25 ml im","90655","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37.93",,,,,,,"fee schedule","37.93","37.93",
"Iiv3 vacc no prsv 0.5 ml im","90656","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","51.41",,,,,,,"fee schedule","37.93","51.41",
"Iiv3 vacc no prsv 0.5 ml im","90656","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","51.41",,,,,,,"fee schedule","37.93","51.41",
"Iiv3 vacc no prsv 0.5 ml im","90656","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","51.41",,,,,,,"fee schedule","37.93","51.41",
"Iiv3 vacc no prsv 0.5 ml im","90656","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37.93",,,,,,,"fee schedule","37.93","51.41",
"Iiv3 vaccine splt 0.25 ml im","90657","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","25.14",,,,,,,"fee schedule","25.14","37.93",
"Iiv3 vaccine splt 0.25 ml im","90657","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","25.14",,,,,,,"fee schedule","25.14","37.93",
"Iiv3 vaccine splt 0.25 ml im","90657","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","25.14",,,,,,,"fee schedule","25.14","37.93",
"Iiv3 vaccine splt 0.25 ml im","90657","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37.93",,,,,,,"fee schedule","25.14","37.93",
"Iiv3 vaccine splt 0.5 ml im","90658","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","50.27",,,,,,,"fee schedule","37.93","50.27",
"Iiv3 vaccine splt 0.5 ml im","90658","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","50.27",,,,,,,"fee schedule","37.93","50.27",
"Iiv3 vaccine splt 0.5 ml im","90658","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","50.27",,,,,,,"fee schedule","37.93","50.27",
"Iiv3 vaccine splt 0.5 ml im","90658","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37.93",,,,,,,"fee schedule","37.93","50.27",
"Laiv3 vaccine intranasal","90660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","66.4",,,,,,,"fee schedule","50.18","66.4",
"Laiv3 vaccine intranasal","90660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","66.4",,,,,,,"fee schedule","50.18","66.4",
"Laiv3 vaccine intranasal","90660","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","66.4",,,,,,,"fee schedule","50.18","66.4",
"Laiv3 vaccine intranasal","90660","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","50.18",,,,,,,"fee schedule","50.18","66.4",
"Cciiv3 vac no prsv 0.5 ml im","90661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","84.75",,,,,,,"fee schedule","84.75","84.75",
"Cciiv3 vac no prsv 0.5 ml im","90661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","84.75",,,,,,,"fee schedule","84.75","84.75",
"Cciiv3 vac no prsv 0.5 ml im","90661","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","84.75",,,,,,,"fee schedule","84.75","84.75",
"Iiv no prsv increased ag im","90662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","192.03",,,,,,,"fee schedule","189.91","192.03",
"Iiv no prsv increased ag im","90662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","192.03",,,,,,,"fee schedule","189.91","192.03",
"Iiv no prsv increased ag im","90662","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","192.03",,,,,,,"fee schedule","189.91","192.03",
"Iiv no prsv increased ag im","90662","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","189.91",,,,,,,"fee schedule","189.91","192.03",
"Pcv13 vaccine im","90670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","593.37",,,,,,,"fee schedule","593.37","780.26",
"Pcv13 vaccine im","90670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","593.37",,,,,,,"fee schedule","593.37","780.26",
"Pcv13 vaccine im","90670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","593.37",,,,,,,"fee schedule","593.37","780.26",
"Pcv13 vaccine im","90670","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","780.26",,,,,,,"fee schedule","593.37","780.26",
"Pcv15 vaccine im","90671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","600.64",,,,,,,"fee schedule","600.64","600.64",
"Pcv15 vaccine im","90671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","600.64",,,,,,,"fee schedule","600.64","600.64",
"Pcv15 vaccine im","90671","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","600.64",,,,,,,"fee schedule","600.64","600.64",
"Laiv4 vaccine intranasal","90672","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","91.12",,,,,,,"fee schedule","91.12","91.12",
"Riv3 vaccine no preserv im","90673","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","192.03",,,,,,,"fee schedule","192.03","192.03",
"Riv3 vaccine no preserv im","90673","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","192.03",,,,,,,"fee schedule","192.03","192.03",
"Riv3 vaccine no preserv im","90673","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","192.03",,,,,,,"fee schedule","192.03","192.03",
"Cciiv4 vac no prsv 0.5 ml im","90674","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","95.36",,,,,,,"fee schedule","95.36","95.36",
"Rabies vaccine im","90675","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","730.65",,,,,,,"fee schedule","730.65","970.33",
"Rabies vaccine im","90675","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","730.65",,,,,,,"fee schedule","730.65","970.33",
"Rabies vaccine im","90675","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","730.65",,,,,,,"fee schedule","730.65","970.33",
"Rabies vaccine im","90675","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","970.33",,,,,,,"fee schedule","730.65","970.33",
"Rabies vaccine id","90676","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","771.4",,,,,,,"fee schedule","771.4","771.4",
"Pcv20 vaccine im","90677","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","719.67",,,,,,,"fee schedule","719.67","719.67",
"Pcv20 vaccine im","90677","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","719.67",,,,,,,"fee schedule","719.67","719.67",
"Pcv20 vaccine im","90677","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","719.67",,,,,,,"fee schedule","719.67","719.67",
"Rv5 vacc 3 dose live oral","90680","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","343.42",,,,,,,"fee schedule","343.42","343.42",
"Rv1 vacc 2 dose live oral","90681","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","506.24",,,,,,,"fee schedule","506.24","506.24",
"Riv4 vacc recombinant dna im","90682","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","189.91",,,,,,,"fee schedule","189.91","189.91",
"Pcv21 vaccine im","90684","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","754.15",,,,,,,"fee schedule","754.15","754.15",
"Pcv21 vaccine im","90684","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","754.15",,,,,,,"fee schedule","754.15","754.15",
"Pcv21 vaccine im","90684","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","754.15",,,,,,,"fee schedule","754.15","754.15",
"Iiv4 vacc no prsv 0.25 ml im","90685","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","68.96",,,,,,,"fee schedule","68.96","68.96",
"Iiv4 vacc no prsv 0.5 ml im","90686","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","64.51",,,,,,,"fee schedule","64.51","64.51",
"Iiv4 vaccine splt 0.25 ml im","90687","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","31.88",,,,,,,"fee schedule","31.88","31.88",
"Iiv4 vaccine splt 0.5 ml im","90688","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","60.48",,,,,,,"fee schedule","60.48","60.48",
"Typhoid vaccine oral","90690","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","281.36",,,,,,,"fee schedule","281.36","281.36",
"Typhoid vaccine im","90691","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","370.19",,,,,,,"fee schedule","370.19","370.19",
"Dtap-ipv vaccine 4-6 yrs im","90696","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","433.3",,,,,,,"fee schedule","433.3","433.3",
"Dtap-ipv/hib vaccine im","90698","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","403.61",,,,,,,"fee schedule","403.61","403.61",
"Dtap vaccine < 7 yrs im","90700","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","113.71",,,,,,,"fee schedule","113.71","113.71",
"Dt vaccine under 7 yrs im","90702","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","226.47",,,,,,,"fee schedule","226.47","226.47",
"Mmr vaccine sc","90707","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","318.56",,,,,,,"fee schedule","318.56","318.56",
"Mmrv vaccine sc","90710","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","913.1",,,,,,,"fee schedule","913.1","913.1",
"Poliovirus ipv sc/im","90713","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","139.22",,,,,,,"fee schedule","139.22","139.22",
"Td vacc no presv 7 yrs+ im","90714","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","78.11",,,,,,,"fee schedule","78.11","82.09",
"Td vacc no presv 7 yrs+ im","90714","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","78.11",,,,,,,"fee schedule","78.11","82.09",
"Td vacc no presv 7 yrs+ im","90714","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","78.11",,,,,,,"fee schedule","78.11","82.09",
"Td vacc no presv 7 yrs+ im","90714","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","82.09",,,,,,,"fee schedule","78.11","82.09",
"Tdap vaccine 7 yrs/> im","90715","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","89.86",,,,,,,"fee schedule","89.86","112.22",
"Tdap vaccine 7 yrs/> im","90715","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","89.86",,,,,,,"fee schedule","89.86","112.22",
"Tdap vaccine 7 yrs/> im","90715","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","89.86",,,,,,,"fee schedule","89.86","112.22",
"Tdap vaccine 7 yrs/> im","90715","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","112.22",,,,,,,"fee schedule","89.86","112.22",
"Var vaccine live subq","90716","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","551.69",,,,,,,"fee schedule","551.69","551.69",
"Yellow fever vaccine subq","90717","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","452.02",,,,,,,"fee schedule","452.02","452.02",
"Dtap-hep b-ipv vaccine im","90723","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","334.81",,,,,,,"fee schedule","334.81","334.81",
"Ppsv23 vacc 2 yrs+ subq/im","90732","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","306.99",,,,,,,"fee schedule","306.99","406.57",
"Ppsv23 vacc 2 yrs+ subq/im","90732","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","306.99",,,,,,,"fee schedule","306.99","406.57",
"Ppsv23 vacc 2 yrs+ subq/im","90732","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","306.99",,,,,,,"fee schedule","306.99","406.57",
"Ppsv23 vacc 2 yrs+ subq/im","90732","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","406.57",,,,,,,"fee schedule","306.99","406.57",
"Mpsv4 vaccine subq","90733","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","249.6",,,,,,,"fee schedule","249.6","249.6",
"Mcv4 menacwy vaccine im","90734","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","509.47",,,,,,,"fee schedule","509.47","509.47",
"Hzv vaccine live subq","90736","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","886.48",,,,,,,"fee schedule","886.48","886.48",
"Inactivated je vacc im","90738","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1036.46",,,,,,,"fee schedule","1036.46","1036.46",
"Hepb vacc 2 dose adult im","90739","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","408.38",,,,,,,"fee schedule","408.38","444.47",
"Hepb vacc 2 dose adult im","90739","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","408.38",,,,,,,"fee schedule","408.38","444.47",
"Hepb vacc 2 dose adult im","90739","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","408.38",,,,,,,"fee schedule","408.38","444.47",
"Hepb vacc 2 dose adult im","90739","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","444.47",,,,,,,"fee schedule","408.38","444.47",
"Hepb vacc 3 dose immunsup im","90740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","378.17",,,,,,,"fee schedule","378.17","477.22",
"Hepb vacc 3 dose immunsup im","90740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","378.17",,,,,,,"fee schedule","378.17","477.22",
"Hepb vacc 3 dose immunsup im","90740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","378.17",,,,,,,"fee schedule","378.17","477.22",
"Hepb vacc 3 dose immunsup im","90740","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","477.22",,,,,,,"fee schedule","378.17","477.22",
"Hepb vacc 2 dose adolesc im","90743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","172.83",,,,,,,"fee schedule","172.83","250.75",
"Hepb vacc 2 dose adolesc im","90743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","172.83",,,,,,,"fee schedule","172.83","250.75",
"Hepb vacc 2 dose adolesc im","90743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","172.83",,,,,,,"fee schedule","172.83","250.75",
"Hepb vacc 2 dose adolesc im","90743","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","250.75",,,,,,,"fee schedule","172.83","250.75",
"Hepb vacc 3 dose ped/adol im","90744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","72.84",,,,,,,"fee schedule","72.84","95.65",
"Hepb vacc 3 dose ped/adol im","90744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","72.84",,,,,,,"fee schedule","72.84","95.65",
"Hepb vacc 3 dose ped/adol im","90744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","72.84",,,,,,,"fee schedule","72.84","95.65",
"Hepb vacc 3 dose ped/adol im","90744","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","95.65",,,,,,,"fee schedule","72.84","95.65",
"Hepb vaccine 3 dose adult im","90746","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","161.86",,,,,,,"fee schedule","161.86","236.15",
"Hepb vaccine 3 dose adult im","90746","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","161.86",,,,,,,"fee schedule","161.86","236.15",
"Hepb vaccine 3 dose adult im","90746","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","161.86",,,,,,,"fee schedule","161.86","236.15",
"Hepb vaccine 3 dose adult im","90746","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","236.15",,,,,,,"fee schedule","161.86","236.15",
"Hepb vacc 4 dose immunsup im","90747","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","323.73",,,,,,,"fee schedule","323.73","477.22",
"Hepb vacc 4 dose immunsup im","90747","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","323.73",,,,,,,"fee schedule","323.73","477.22",
"Hepb vacc 4 dose immunsup im","90747","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","323.73",,,,,,,"fee schedule","323.73","477.22",
"Hepb vacc 4 dose immunsup im","90747","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","477.22",,,,,,,"fee schedule","323.73","477.22",
"Hib-hepb vaccine im","90748","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","139.48",,,,,,,"fee schedule","139.48","139.48",
"Cciiv4 vacc abx free im","90756","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","90.39",,,,,,,"fee schedule","90.39","90.39",
"Hep b vac 3ag 10mcg 3 dos im","90759","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","169.77",,,,,,,"fee schedule","169.77","169.77",
"Hep b vac 3ag 10mcg 3 dos im","90759","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","169.77",,,,,,,"fee schedule","169.77","169.77",
"Hep b vac 3ag 10mcg 3 dos im","90759","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","169.77",,,,,,,"fee schedule","169.77","169.77",
"Coronavirus vaccine 5","91304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","371.54",,,,,,,"fee schedule","371.54","371.54",
"Coronavirus vaccine 5","91304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","371.54",,,,,,,"fee schedule","371.54","371.54",
"Coronavirus vaccine 5","91304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","371.54",,,,,,,"fee schedule","371.54","371.54",
"Sarscov2 vac 3mcg trs-suc im","91318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","150.77",,,,,,,"fee schedule","150.77","150.77",
"Sarscov2 vac 3mcg trs-suc im","91318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","150.77",,,,,,,"fee schedule","150.77","150.77",
"Sarscov2 vac 3mcg trs-suc im","91318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","150.77",,,,,,,"fee schedule","150.77","150.77",
"Sarscv2 vac 10mcg trs-suc im","91319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","201.89",,,,,,,"fee schedule","201.89","201.89",
"Sarscv2 vac 10mcg trs-suc im","91319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","201.89",,,,,,,"fee schedule","201.89","201.89",
"Sarscv2 vac 10mcg trs-suc im","91319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","201.89",,,,,,,"fee schedule","201.89","201.89",
"Sarscv2 vac 30mcg trs-suc im","91320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","358.56",,,,,,,"fee schedule","358.56","358.56",
"Sarscv2 vac 30mcg trs-suc im","91320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","358.56",,,,,,,"fee schedule","358.56","358.56",
"Sarscv2 vac 30mcg trs-suc im","91320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","358.56",,,,,,,"fee schedule","358.56","358.56",
"Sarscov2 vac 25 mcg/.25ml im","91321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","338.24",,,,,,,"fee schedule","338.24","338.24",
"Sarscov2 vac 25 mcg/.25ml im","91321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","338.24",,,,,,,"fee schedule","338.24","338.24",
"Sarscov2 vac 25 mcg/.25ml im","91321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","338.24",,,,,,,"fee schedule","338.24","338.24",
"Sarscov2 vac 50 mcg/0.5ml im","91322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","371.8",,,,,,,"fee schedule","371.8","371.8",
"Sarscov2 vac 50 mcg/0.5ml im","91322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","371.8",,,,,,,"fee schedule","371.8","371.8",
"Sarscov2 vac 50 mcg/0.5ml im","91322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","371.8",,,,,,,"fee schedule","371.8","371.8",
"Hydration iv infusion init","96360","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","622.95",,,,,,,"fee schedule","622.95","622.95",
"Hydrate iv infusion add-on","96361","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","129.2",,,,,,,"fee schedule","129.2","129.2",
"In111 satumomab","A4642","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5477.92",,,,,,,"fee schedule","5477.92","5477.92",
"Tc99m sestamibi","A9500","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","395.21",,,,,,,"fee schedule","395.21","395.21",
"Tc99m tetrofosmin","A9502","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","376.88",,,,,,,"fee schedule","376.88","376.88",
"Tc99m medronate","A9503","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","57.51",,,,,,,"fee schedule","57.51","57.51",
"Tc99m apcitide","A9504","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1640.82",,,,,,,"fee schedule","1640.82","1640.82",
"Tl201 thallium","A9505","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","414.77",,,,,,,"fee schedule","414.77","414.77",
"In111 capromab","A9507","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3512.86",,,,,,,"fee schedule","3512.86","3512.86",
"I131 iodobenguate, dx","A9508","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3325.68",,,,,,,"fee schedule","3325.68","3325.68",
"Iodine I-123 sod iodide mil","A9509","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1064.5",,,,,,,"fee schedule","1064.5","1064.5",
"Tc99m disofenin","A9510","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","227.59",,,,,,,"fee schedule","227.59","227.59",
"Tc99m pertechnetate","A9512","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","46.49",,,,,,,"fee schedule","46.49","46.49",
"Lutetium lu 177 dotatat ther","A9513","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","878.69",,,,,,,"fee schedule","878.69","878.69",
"Iodine I-123 sod iodide mic","A9516","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","380.53",,,,,,,"fee schedule","380.53","380.53",
"I131 iodide cap, rx","A9517","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","70.15",,,,,,,"fee schedule","70.15","70.15",
"Tc99m exametazime","A9521","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5228.32",,,,,,,"fee schedule","5228.32","5228.32",
"I131 serum albumin, dx","A9524","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","275.3",,,,,,,"fee schedule","275.3","275.3",
"Iodine I-125 sodium iodide","A9527","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","106.02",,,,,,,"fee schedule","106.02","106.02",
"Iodine i-131 iodide cap, dx","A9528","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","357.27",,,,,,,"fee schedule","357.27","357.27",
"I131 iodide sol, rx","A9530","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","45.29",,,,,,,"fee schedule","45.29","45.29",
"I131 max 100uci","A9531","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15.9",,,,,,,"fee schedule","15.9","15.9",
"I125 serum albumin, dx","A9532","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","775.76",,,,,,,"fee schedule","775.76","775.76",
"Tc99m depreotide","A9536","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2616",,,,,,,"fee schedule","2616","2616",
"Tc99m mebrofenin","A9537","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","209.21",,,,,,,"fee schedule","209.21","209.21",
"Tc99m pyrophosphate","A9538","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","152.93",,,,,,,"fee schedule","152.93","152.93",
"Tc99m pentetate","A9539","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","179.85",,,,,,,"fee schedule","179.85","179.85",
"Tc99m maa","A9540","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","119.92",,,,,,,"fee schedule","119.92","119.92",
"Tc99m sulfur colloid","A9541","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","203.11",,,,,,,"fee schedule","203.11","203.11",
"In111 ibritumomab, dx","A9542","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13562.05",,,,,,,"fee schedule","13562.05","13562.05",
"Y90 ibritumomab, rx","A9543","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","189311.16",,,,,,,"fee schedule","189311.16","189311.16",
"Co57/58","A9546","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.66",,,,,,,"fee schedule","3.66","3.66",
"In111 oxyquinoline","A9547","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1118.35",,,,,,,"fee schedule","1118.35","1118.35",
"In111 pentetate","A9548","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","670.5",,,,,,,"fee schedule","670.5","670.5",
"Tc99m succimer","A9551","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1779.07",,,,,,,"fee schedule","1779.07","1779.07",
"F18 fdg","A9552","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1002.09",,,,,,,"fee schedule","1002.09","1002.09",
"Cr51 chromate","A9553","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1334.92",,,,,,,"fee schedule","1334.92","1334.92",
"I125 iothalamate, dx","A9554","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","450.28",,,,,,,"fee schedule","450.28","450.28",
"Rb82 rubidium","A9555","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1624.9",,,,,,,"fee schedule","1624.9","1624.9",
"Ga67 gallium","A9556","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","83.2",,,,,,,"fee schedule","83.2","83.2",
"Tc99m bicisate","A9557","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1421.78",,,,,,,"fee schedule","1421.78","1421.78",
"Xe133 xenon 10mci","A9558","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","767.17",,,,,,,"fee schedule","767.17","767.17",
"Co57 cyano","A9559","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","712.1",,,,,,,"fee schedule","712.1","712.1",
"Tc99m labeled rbc","A9560","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","354.84",,,,,,,"fee schedule","354.84","354.84",
"Tc99m oxidronate","A9561","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","168.85",,,,,,,"fee schedule","168.85","168.85",
"Tc99m mertiatide","A9562","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2740.81",,,,,,,"fee schedule","2740.81","2740.81",
"P32 na phosphate","A9563","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1523.32",,,,,,,"fee schedule","1523.32","1523.32",
"P32 chromic phosphate","A9564","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","572.65",,,,,,,"fee schedule","572.65","572.65",
"Technetium tc-99m aerosol","A9567","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","77.1",,,,,,,"fee schedule","77.1","77.1",
"Technetium tc99m arcitumomab","A9568","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4187.07",,,,,,,"fee schedule","4187.07","4187.07",
"Technetium TC-99m auto WBC","A9569","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5584.38",,,,,,,"fee schedule","5584.38","5584.38",
"Indium In-111 auto WBC","A9570","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13633.01",,,,,,,"fee schedule","13633.01","13633.01",
"Indium IN-111 auto platelet","A9571","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13633.01",,,,,,,"fee schedule","13633.01","13633.01",
"Indium In-111 pentetreotide","A9572","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21945.95",,,,,,,"fee schedule","21945.95","21945.95",
"Inj, gadopiclenol, 1 ml","A9573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.99",,,,,,,"fee schedule","7.99","7.99",
"Inj, gadopiclenol, 1 ml","A9573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.99",,,,,,,"fee schedule","7.99","7.99",
"Inj, gadopiclenol, 1 ml","A9573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.99",,,,,,,"fee schedule","7.99","7.99",
"Inj gadoterate meglumi 0.1ml","A9575","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.27",,,,,,,"fee schedule","0.27","0.61",
"Inj gadoterate meglumi 0.1ml","A9575","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.27",,,,,,,"fee schedule","0.27","0.61",
"Inj gadoterate meglumi 0.1ml","A9575","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.27",,,,,,,"fee schedule","0.27","0.61",
"Inj gadoterate meglumi 0.1ml","A9575","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.61",,,,,,,"fee schedule","0.27","0.61",
"Inj prohance multipack","A9576","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.3",,,,,,,"fee schedule","3.3","4.82",
"Inj prohance multipack","A9576","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.3",,,,,,,"fee schedule","3.3","4.82",
"Inj prohance multipack","A9576","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.3",,,,,,,"fee schedule","3.3","4.82",
"Inj prohance multipack","A9576","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.82",,,,,,,"fee schedule","3.3","4.82",
"Inj multihance","A9577","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.17",,,,,,,"fee schedule","4.17","6.41",
"Inj multihance","A9577","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.17",,,,,,,"fee schedule","4.17","6.41",
"Inj multihance","A9577","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.17",,,,,,,"fee schedule","4.17","6.41",
"Inj multihance","A9577","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.41",,,,,,,"fee schedule","4.17","6.41",
"Inj multihance multipack","A9578","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.16",,,,,,,"fee schedule","4.16","6.31",
"Inj multihance multipack","A9578","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.16",,,,,,,"fee schedule","4.16","6.31",
"Inj multihance multipack","A9578","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.16",,,,,,,"fee schedule","4.16","6.31",
"Inj multihance multipack","A9578","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.31",,,,,,,"fee schedule","4.16","6.31",
"Gad-base MR contrast NOS,1ml","A9579","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.43",,,,,,,"fee schedule","3.43","5.26",
"Gad-base MR contrast NOS,1ml","A9579","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.43",,,,,,,"fee schedule","3.43","5.26",
"Gad-base MR contrast NOS,1ml","A9579","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.43",,,,,,,"fee schedule","3.43","5.26",
"Gad-base MR contrast NOS,1ml","A9579","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.26",,,,,,,"fee schedule","3.43","5.26",
"Sodium fluoride F-18","A9580","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","888.31",,,,,,,"fee schedule","888.31","888.31",
"Gadoxetate disodium inj","A9581","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","33.84",,,,,,,"fee schedule","33.84","49.97",
"Gadoxetate disodium inj","A9581","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","33.84",,,,,,,"fee schedule","33.84","49.97",
"Gadoxetate disodium inj","A9581","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","33.84",,,,,,,"fee schedule","33.84","49.97",
"Gadoxetate disodium inj","A9581","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","49.97",,,,,,,"fee schedule","33.84","49.97",
"Iodine I-123 iobenguane","A9582","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8196.69",,,,,,,"fee schedule","8196.69","8196.69",
"Gadobutrol injection","A9585","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.29",,,,,,,"fee schedule","0.61","1.29",
"Gadobutrol injection","A9585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.61",,,,,,,"fee schedule","0.61","1.29",
"Gadobutrol injection","A9585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.61",,,,,,,"fee schedule","0.61","1.29",
"Gadobutrol injection","A9585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.61",,,,,,,"fee schedule","0.61","1.29",
"Florbetapir F18","A9586","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10268.88",,,,,,,"fee schedule","10268.88","10268.88",
"Insti hexaminolevulinate hcl","A9589","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3170.35",,,,,,,"fee schedule","3170.35","3978.18",
"Insti hexaminolevulinate hcl","A9589","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3170.35",,,,,,,"fee schedule","3170.35","3978.18",
"Insti hexaminolevulinate hcl","A9589","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3170.35",,,,,,,"fee schedule","3170.35","3978.18",
"Insti hexaminolevulinate hcl","A9589","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3978.18",,,,,,,"fee schedule","3170.35","3978.18",
"Iodine i-131 iobenguane 1mci","A9590","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1085.31",,,,,,,"fee schedule","1085.31","1085.31",
"Sr89 strontium","A9600","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6935.68",,,,,,,"fee schedule","6935.68","6935.68",
"Sm 153 lexidronam","A9604","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","54373.92",,,,,,,"fee schedule","54373.92","54373.92",
"Radium ra223 dichloride ther","A9606","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","476.36",,,,,,,"fee schedule","476.36","476.36",
"Cocaine hcl nasal solution","C9046","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.1",,,,,,,"fee schedule","4.1","4.1",
"Injection, caplacizumab-yhdp","C9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2337.28",,,,,,,"fee schedule","2337.28","2337.28",
"Artiss fibrin sealant","C9250","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","531.73",,,,,,,"fee schedule","531.73","531.73",
"Bevacizumab injection","C9257","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.75",,,,,,,"fee schedule","6.75","6.75",
"Injection, cangrelor","C9460","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","51.91",,,,,,,"fee schedule","51.91","51.91",
"Injection, delafloxacin","C9462","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.67",,,,,,,"fee schedule","1.67","1.67",
"Sotalol hydrochloride IV","C9482","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","33.87",,,,,,,"fee schedule","33.87","33.87",
"Conivaptan HCL","C9488","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","106.16",,,,,,,"fee schedule","106.16","106.16",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1949",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2467",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2619",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2619",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3031",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2573",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2316",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3353",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2467",,,,,,,"fee schedule","1949","3353",
"Colorectal scrn; hi risk ind","G0105","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2932",,,,,,,"fee schedule","1949","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","2510",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO / PPO","2467",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2619",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1901",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Health Net","HMO/PPO","3353",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2316",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2619",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Cigna","HMO/PPO","3031",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2932",,,,,,,"fee schedule","1901","3353",
"Colon ca scrn not hi rsk ind","G0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Aetna","HMO/PPO","2467",,,,,,,"fee schedule","1901","3353",
"Inj., omadacycline, 1 mg","J0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.89",,,,,,,"fee schedule","8.89","11.23",
"Inj., omadacycline, 1 mg","J0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.89",,,,,,,"fee schedule","8.89","11.23",
"Inj., omadacycline, 1 mg","J0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.89",,,,,,,"fee schedule","8.89","11.23",
"Inj., omadacycline, 1 mg","J0121","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11.23",,,,,,,"fee schedule","8.89","11.23",
"Inj., eravacycline, 1 mg","J0122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.77",,,,,,,"fee schedule","2.77","3.47",
"Inj., eravacycline, 1 mg","J0122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.77",,,,,,,"fee schedule","2.77","3.47",
"Inj., eravacycline, 1 mg","J0122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.77",,,,,,,"fee schedule","2.77","3.47",
"Inj., eravacycline, 1 mg","J0122","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.47",,,,,,,"fee schedule","2.77","3.47",
"Abatacept injection","J0129","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","174.31",,,,,,,"fee schedule","99.77","186.73",
"Abatacept injection","J0129","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","176.04",,,,,,,"fee schedule","99.77","186.73",
"Abatacept injection","J0129","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","99.77",,,,,,,"fee schedule","99.77","186.73",
"Abatacept injection","J0129","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","99.77",,,,,,,"fee schedule","99.77","186.73",
"Abatacept injection","J0129","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","99.77",,,,,,,"fee schedule","99.77","186.73",
"Abatacept injection","J0129","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","186.73",,,,,,,"fee schedule","99.77","186.73",
"Abciximab injection","J0130","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2113.13",,,,,,,"fee schedule","2113.13","2113.13",
"Acetaminophen injection","J0131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.12",,,,,,,"fee schedule","0.12","1.92",
"Acetaminophen injection","J0131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.12",,,,,,,"fee schedule","0.12","1.92",
"Acetaminophen injection","J0131","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.12",,,,,,,"fee schedule","0.12","1.92",
"Acetaminophen injection","J0131","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.92",,,,,,,"fee schedule","0.12","1.92",
"Acetylcysteine injection","J0132","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.03",,,,,,,"fee schedule","1.03","3.75",
"Acetylcysteine injection","J0132","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.03",,,,,,,"fee schedule","1.03","3.75",
"Acetylcysteine injection","J0132","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.03",,,,,,,"fee schedule","1.03","3.75",
"Acetylcysteine injection","J0132","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.75",,,,,,,"fee schedule","1.03","3.75",
"Acyclovir injection","J0133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.08",,,,,,,"fee schedule","0.08","0.24",
"Acyclovir injection","J0133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.08",,,,,,,"fee schedule","0.08","0.24",
"Acyclovir injection","J0133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.08",,,,,,,"fee schedule","0.08","0.24",
"Acyclovir injection","J0133","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.24",,,,,,,"fee schedule","0.08","0.24",
"Inj acetaminophen -fresenius","J0134","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.12",,,,,,,"fee schedule","0.12","0.12",
"Inj acetaminophen -fresenius","J0134","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.12",,,,,,,"fee schedule","0.12","0.12",
"Inj acetaminophen -fresenius","J0134","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.12",,,,,,,"fee schedule","0.12","0.12",
"Inj, acetaminophen (b braun)","J0136","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.11",,,,,,,"fee schedule","0.11","0.11",
"Inj, acetaminophen (b braun)","J0136","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.11",,,,,,,"fee schedule","0.11","0.11",
"Inj, acetaminophen (b braun)","J0136","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.11",,,,,,,"fee schedule","0.11","0.11",
"Inj, acetaminophen (hikma)","J0137","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.06",,,,,,,"fee schedule","0.06","0.06",
"Inj, acetaminophen (hikma)","J0137","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.06",,,,,,,"fee schedule","0.06","0.06",
"Inj, acetaminophen (hikma)","J0137","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.06",,,,,,,"fee schedule","0.06","0.06",
"Injection, acetaminoph 10 mg","J0138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.5",,,,,,,"fee schedule","0.5","0.5",
"Injection, acetaminoph 10 mg","J0138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.5",,,,,,,"fee schedule","0.5","0.5",
"Injection, acetaminoph 10 mg","J0138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.5",,,,,,,"fee schedule","0.5","0.5",
"Adenosine inj 1mg","J0153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.89",,,,,,,"fee schedule","0.89","2.12",
"Adenosine inj 1mg","J0153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.89",,,,,,,"fee schedule","0.89","2.12",
"Adenosine inj 1mg","J0153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.89",,,,,,,"fee schedule","0.89","2.12",
"Adenosine inj 1mg","J0153","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.12",,,,,,,"fee schedule","0.89","2.12",
"Adrenalin epinephrine inject","J0171","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.85",,,,,,,"fee schedule","1.68","2.85",
"Adrenalin epinephrine inject","J0171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.68",,,,,,,"fee schedule","1.68","2.85",
"Adrenalin epinephrine inject","J0171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.68",,,,,,,"fee schedule","1.68","2.85",
"Adrenalin epinephrine inject","J0171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.68",,,,,,,"fee schedule","1.68","2.85",
"Inj, aducanumab-avwa, 2 mg","J0172","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13.75",,,,,,,"fee schedule","13.75","13.75",
"Inj, aducanumab-avwa, 2 mg","J0172","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13.75",,,,,,,"fee schedule","13.75","13.75",
"Inj, aducanumab-avwa, 2 mg","J0172","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13.75",,,,,,,"fee schedule","13.75","13.75",
"Inj, epinephrine (belcher)","J0173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.18",,,,,,,"fee schedule","5.18","5.18",
"Inj, epinephrine (belcher)","J0173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.18",,,,,,,"fee schedule","5.18","5.18",
"Inj, epinephrine (belcher)","J0173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.18",,,,,,,"fee schedule","5.18","5.18",
"Inj, lecanemab-irmb","J0174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.06",,,,,,,"fee schedule","3.06","3.06",
"Inj, lecanemab-irmb","J0174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.06",,,,,,,"fee schedule","3.06","3.06",
"Inj, lecanemab-irmb","J0174","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.06",,,,,,,"fee schedule","3.06","3.06",
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.62",,,,,,,"fee schedule","9.62","9.62",
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.62",,,,,,,"fee schedule","9.62","9.62",
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.62",,,,,,,"fee schedule","9.62","9.62",
"Inj, aflibercept hd, 1 mg","J0177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","738.7",,,,,,,"fee schedule","738.7","738.7",
"Inj, aflibercept hd, 1 mg","J0177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","738.7",,,,,,,"fee schedule","738.7","738.7",
"Inj, aflibercept hd, 1 mg","J0177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","738.7",,,,,,,"fee schedule","738.7","738.7",
"Aflibercept injection","J0178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1830.48",,,,,,,"fee schedule","1830.48","3181.65",
"Aflibercept injection","J0178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1830.48",,,,,,,"fee schedule","1830.48","3181.65",
"Aflibercept injection","J0178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1830.48",,,,,,,"fee schedule","1830.48","3181.65",
"Aflibercept injection","J0178","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3181.65",,,,,,,"fee schedule","1830.48","3181.65",
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","781.97",,,,,,,"fee schedule","781.97","1076.71",
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","781.97",,,,,,,"fee schedule","781.97","1076.71",
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","781.97",,,,,,,"fee schedule","781.97","1076.71",
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1076.71",,,,,,,"fee schedule","781.97","1076.71",
"Agalsidase beta injection","J0180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","585.96",,,,,,,"fee schedule","512.53","623.06",
"Agalsidase beta injection","J0180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","512.53",,,,,,,"fee schedule","512.53","623.06",
"Agalsidase beta injection","J0180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","580.16",,,,,,,"fee schedule","512.53","623.06",
"Agalsidase beta injection","J0180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","512.53",,,,,,,"fee schedule","512.53","623.06",
"Agalsidase beta injection","J0180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","512.53",,,,,,,"fee schedule","512.53","623.06",
"Agalsidase beta injection","J0180","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","623.06",,,,,,,"fee schedule","512.53","623.06",
"Inj., aprepitant, 1 mg","J0185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.93",,,,,,,"fee schedule","3.93","6.82",
"Inj., aprepitant, 1 mg","J0185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.93",,,,,,,"fee schedule","3.93","6.82",
"Inj., aprepitant, 1 mg","J0185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.93",,,,,,,"fee schedule","3.93","6.82",
"Inj., aprepitant, 1 mg","J0185","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.82",,,,,,,"fee schedule","3.93","6.82",
"Injection, alemtuzumab","J0202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6245.21",,,,,,,"fee schedule","5615.43","6609.86",
"Injection, alemtuzumab","J0202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","6183.37",,,,,,,"fee schedule","5615.43","6609.86",
"Injection, alemtuzumab","J0202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5615.43",,,,,,,"fee schedule","5615.43","6609.86",
"Injection, alemtuzumab","J0202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5615.43",,,,,,,"fee schedule","5615.43","6609.86",
"Injection, alemtuzumab","J0202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5615.43",,,,,,,"fee schedule","5615.43","6609.86",
"Injection, alemtuzumab","J0202","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6609.86",,,,,,,"fee schedule","5615.43","6609.86",
"Alglucerase injection","J0205","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","113.78",,,,,,,"fee schedule","113.78","113.78",
"Inj allopurinol sodium 1 mg","J0206","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.24",,,,,,,"fee schedule","10.24","10.24",
"Inj allopurinol sodium 1 mg","J0206","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.24",,,,,,,"fee schedule","10.24","10.24",
"Inj allopurinol sodium 1 mg","J0206","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.24",,,,,,,"fee schedule","10.24","10.24",
"Amifostine","J0207","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3323.02",,,,,,,"fee schedule","3323.02","3323.02",
"Methyldopate hcl injection","J0210","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","169.53",,,,,,,"fee schedule","169.53","169.53",
"Alefacept","J0215","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","95.44",,,,,,,"fee schedule","95.44","95.44",
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1023.44",,,,,,,"fee schedule","1023.44","1023.44",
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1023.44",,,,,,,"fee schedule","1023.44","1023.44",
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1023.44",,,,,,,"fee schedule","1023.44","1023.44",
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","876.85",,,,,,,"fee schedule","876.85","876.85",
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","876.85",,,,,,,"fee schedule","876.85","876.85",
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","876.85",,,,,,,"fee schedule","876.85","876.85",
"Inj aval alfa-nqpt 4mg","J0219","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","178.98",,,,,,,"fee schedule","178.98","178.98",
"Inj aval alfa-nqpt 4mg","J0219","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","178.98",,,,,,,"fee schedule","178.98","178.98",
"Inj aval alfa-nqpt 4mg","J0219","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","178.98",,,,,,,"fee schedule","178.98","178.98",
"Alglucosidase alfa injection","J0220","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","250.25",,,,,,,"fee schedule","250.25","250.25",
"Lumizyme injection","J0221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","535.23",,,,,,,"fee schedule","463.6","580.47",
"Lumizyme injection","J0221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","540.59",,,,,,,"fee schedule","463.6","580.47",
"Lumizyme injection","J0221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","463.6",,,,,,,"fee schedule","463.6","580.47",
"Lumizyme injection","J0221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","463.6",,,,,,,"fee schedule","463.6","580.47",
"Lumizyme injection","J0221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","463.6",,,,,,,"fee schedule","463.6","580.47",
"Lumizyme injection","J0221","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","580.47",,,,,,,"fee schedule","463.6","580.47",
"Inj., patisiran, 0.1 mg","J0222","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","227.79",,,,,,,"fee schedule","227.79","332.98",
"Inj., patisiran, 0.1 mg","J0222","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","227.79",,,,,,,"fee schedule","227.79","332.98",
"Inj., patisiran, 0.1 mg","J0222","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","227.79",,,,,,,"fee schedule","227.79","332.98",
"Inj., patisiran, 0.1 mg","J0222","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","332.98",,,,,,,"fee schedule","227.79","332.98",
"Inj givosiran 0.5 mg","J0223","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","267.88",,,,,,,"fee schedule","267.88","360.3",
"Inj givosiran 0.5 mg","J0223","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","267.88",,,,,,,"fee schedule","267.88","360.3",
"Inj givosiran 0.5 mg","J0223","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","267.88",,,,,,,"fee schedule","267.88","360.3",
"Inj givosiran 0.5 mg","J0223","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","360.3",,,,,,,"fee schedule","267.88","360.3",
"Inj. lumasiran, 0.5 mg","J0224","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","733.36",,,,,,,"fee schedule","733.36","733.36",
"Inj. lumasiran, 0.5 mg","J0224","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","733.36",,,,,,,"fee schedule","733.36","733.36",
"Inj. lumasiran, 0.5 mg","J0224","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","733.36",,,,,,,"fee schedule","733.36","733.36",
"Inj, vutrisiran, 1 mg","J0225","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11399.51",,,,,,,"fee schedule","11399.51","11399.51",
"Inj, vutrisiran, 1 mg","J0225","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11399.51",,,,,,,"fee schedule","11399.51","11399.51",
"Inj, vutrisiran, 1 mg","J0225","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11399.51",,,,,,,"fee schedule","11399.51","11399.51",
"Inj, remdesivir, 1 mg?","J0248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14.61",,,,,,,"fee schedule","14.61","14.61",
"Inj, remdesivir, 1 mg?","J0248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14.61",,,,,,,"fee schedule","14.61","14.61",
"Inj, remdesivir, 1 mg?","J0248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14.61",,,,,,,"fee schedule","14.61","14.61",
"Alpha 1 proteinase inhibitor","J0256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","14",,,,,,,"fee schedule","11.87","15.03",
"Alpha 1 proteinase inhibitor","J0256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","13.86",,,,,,,"fee schedule","11.87","15.03",
"Alpha 1 proteinase inhibitor","J0256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.87",,,,,,,"fee schedule","11.87","15.03",
"Alpha 1 proteinase inhibitor","J0256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.87",,,,,,,"fee schedule","11.87","15.03",
"Alpha 1 proteinase inhibitor","J0256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.87",,,,,,,"fee schedule","11.87","15.03",
"Alpha 1 proteinase inhibitor","J0256","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15.03",,,,,,,"fee schedule","11.87","15.03",
"Glassia injection","J0257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","15.13",,,,,,,"fee schedule","12.53","16.62",
"Glassia injection","J0257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12.53",,,,,,,"fee schedule","12.53","16.62",
"Glassia injection","J0257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","14.98",,,,,,,"fee schedule","12.53","16.62",
"Glassia injection","J0257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12.53",,,,,,,"fee schedule","12.53","16.62",
"Glassia injection","J0257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12.53",,,,,,,"fee schedule","12.53","16.62",
"Glassia injection","J0257","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16.62",,,,,,,"fee schedule","12.53","16.62",
"Alprostadil for injection","J0270","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","1.22","1.22",
"Amikacin sulfate injection","J0278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.38",,,,,,,"fee schedule","1.38","3.66",
"Amikacin sulfate injection","J0278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.38",,,,,,,"fee schedule","1.38","3.66",
"Amikacin sulfate injection","J0278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.38",,,,,,,"fee schedule","1.38","3.66",
"Amikacin sulfate injection","J0278","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.66",,,,,,,"fee schedule","1.38","3.66",
"Aminophyllin 250 MG inj","J0280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","25.41",,,,,,,"fee schedule","24.1","25.41",
"Aminophyllin 250 MG inj","J0280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","25.41",,,,,,,"fee schedule","24.1","25.41",
"Aminophyllin 250 MG inj","J0280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","25.41",,,,,,,"fee schedule","24.1","25.41",
"Aminophyllin 250 MG inj","J0280","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","24.1",,,,,,,"fee schedule","24.1","25.41",
"Inj aminocaproic acid 1 gram","J0281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3",,,,,,,"fee schedule","3","3",
"Inj aminocaproic acid 1 gram","J0281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3",,,,,,,"fee schedule","3","3",
"Inj aminocaproic acid 1 gram","J0281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3",,,,,,,"fee schedule","3","3",
"Amiodarone HCl","J0282","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.75",,,,,,,"fee schedule","0.75","2.63",
"Amiodarone HCl","J0282","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.75",,,,,,,"fee schedule","0.75","2.63",
"Amiodarone HCl","J0282","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.75",,,,,,,"fee schedule","0.75","2.63",
"Amiodarone HCl","J0282","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.63",,,,,,,"fee schedule","0.75","2.63",
"Inj, amiodarone (nexterone)","J0283","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.97",,,,,,,"fee schedule","5.97","5.97",
"Inj, amiodarone (nexterone)","J0283","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.97",,,,,,,"fee schedule","5.97","5.97",
"Inj, amiodarone (nexterone)","J0283","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.97",,,,,,,"fee schedule","5.97","5.97",
"Amphotericin B","J0285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","115.15",,,,,,,"fee schedule","115.15","130.73",
"Amphotericin B","J0285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","115.15",,,,,,,"fee schedule","115.15","130.73",
"Amphotericin B","J0285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","115.15",,,,,,,"fee schedule","115.15","130.73",
"Amphotericin B","J0285","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","130.73",,,,,,,"fee schedule","115.15","130.73",
"Amphotericin b lipid complex","J0287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","23.69",,,,,,,"fee schedule","23.69","31.19",
"Amphotericin b lipid complex","J0287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","23.69",,,,,,,"fee schedule","23.69","31.19",
"Amphotericin b lipid complex","J0287","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","23.69",,,,,,,"fee schedule","23.69","31.19",
"Amphotericin b lipid complex","J0287","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","31.19",,,,,,,"fee schedule","23.69","31.19",
"Ampho b cholesteryl sulfate","J0288","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","267.96",,,,,,,"fee schedule","267.96","267.96",
"Amphotericin b liposome inj","J0289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","53.61",,,,,,,"fee schedule","53.61","92.32",
"Amphotericin b liposome inj","J0289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","53.61",,,,,,,"fee schedule","53.61","92.32",
"Amphotericin b liposome inj","J0289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","53.61",,,,,,,"fee schedule","53.61","92.32",
"Amphotericin b liposome inj","J0289","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","92.32",,,,,,,"fee schedule","53.61","92.32",
"Ampicillin 500 MG inj","J0290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.37",,,,,,,"fee schedule","1.37","3.55",
"Ampicillin 500 MG inj","J0290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.37",,,,,,,"fee schedule","1.37","3.55",
"Ampicillin 500 MG inj","J0290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.37",,,,,,,"fee schedule","1.37","3.55",
"Ampicillin 500 MG inj","J0290","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.55",,,,,,,"fee schedule","1.37","3.55",
"Inj., plazomicin, 5 mg","J0291","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.22",,,,,,,"fee schedule","8.22","10.82",
"Inj., plazomicin, 5 mg","J0291","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.22",,,,,,,"fee schedule","8.22","10.82",
"Inj., plazomicin, 5 mg","J0291","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.22",,,,,,,"fee schedule","8.22","10.82",
"Inj., plazomicin, 5 mg","J0291","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.82",,,,,,,"fee schedule","8.22","10.82",
"Ampicillin sodium per 1.5 gm","J0295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.62",,,,,,,"fee schedule","3.62","12.13",
"Ampicillin sodium per 1.5 gm","J0295","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.13",,,,,,,"fee schedule","3.62","12.13",
"Ampicillin sodium per 1.5 gm","J0295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.62",,,,,,,"fee schedule","3.62","12.13",
"Ampicillin sodium per 1.5 gm","J0295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.62",,,,,,,"fee schedule","3.62","12.13",
"Amobarbital 125 MG inj","J0300","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","322.64",,,,,,,"fee schedule","322.64","322.64",
"Succinycholine chloride inj","J0330","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.93",,,,,,,"fee schedule","7.93","7.93",
"Anidulafungin injection","J0348","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.09",,,,,,,"fee schedule","1.09","1.77",
"Anidulafungin injection","J0348","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.09",,,,,,,"fee schedule","1.09","1.77",
"Anidulafungin injection","J0348","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.77",,,,,,,"fee schedule","1.09","1.77",
"Anidulafungin injection","J0348","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.09",,,,,,,"fee schedule","1.09","1.77",
"Inj, rezafungin, 1 mg","J0349","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","23.96",,,,,,,"fee schedule","23.96","23.96",
"Inj, rezafungin, 1 mg","J0349","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","23.96",,,,,,,"fee schedule","23.96","23.96",
"Inj, rezafungin, 1 mg","J0349","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","23.96",,,,,,,"fee schedule","23.96","23.96",
"Hydralazine hcl injection","J0360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.12",,,,,,,"fee schedule","10.12","12.78",
"Hydralazine hcl injection","J0360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.12",,,,,,,"fee schedule","10.12","12.78",
"Hydralazine hcl injection","J0360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.12",,,,,,,"fee schedule","10.12","12.78",
"Hydralazine hcl injection","J0360","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.78",,,,,,,"fee schedule","10.12","12.78",
"Apomorphine hydrochloride","J0364","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","149.17",,,,,,,"fee schedule","149.17","149.17",
"Aprotonin, 10,000 kiu","J0365","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.8",,,,,,,"fee schedule","9.8","9.8",
"Inj metaraminol bitartrate","J0380","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.66",,,,,,,"fee schedule","3.66","3.66",
"Aripiprazole injection","J0400","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","1.22","1.22",
"Inj aripiprazole ext rel 1mg","J0401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.18",,,,,,,"fee schedule","16.18","19.3",
"Inj aripiprazole ext rel 1mg","J0401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.18",,,,,,,"fee schedule","16.18","19.3",
"Inj aripiprazole ext rel 1mg","J0401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.18",,,,,,,"fee schedule","16.18","19.3",
"Inj aripiprazole ext rel 1mg","J0401","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19.3",,,,,,,"fee schedule","16.18","19.3",
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13.51",,,,,,,"fee schedule","13.51","13.51",
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13.51",,,,,,,"fee schedule","13.51","13.51",
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13.51",,,,,,,"fee schedule","13.51","13.51",
"Azithromycin","J0456","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.54",,,,,,,"fee schedule","5.11","10.54",
"Azithromycin","J0456","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.11",,,,,,,"fee schedule","5.11","10.54",
"Azithromycin","J0456","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.11",,,,,,,"fee schedule","5.11","10.54",
"Azithromycin","J0456","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.11",,,,,,,"fee schedule","5.11","10.54",
"Injection, aztreonam, 100 mg","J0457","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.7",,,,,,,"fee schedule","5.7","5.7",
"Injection, aztreonam, 100 mg","J0457","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.7",,,,,,,"fee schedule","5.7","5.7",
"Injection, aztreonam, 100 mg","J0457","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.7",,,,,,,"fee schedule","5.7","5.7",
"Atropine sulfate injection","J0461","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.26",,,,,,,"fee schedule","0.21","0.26",
"Atropine sulfate injection","J0461","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.26",,,,,,,"fee schedule","0.21","0.26",
"Atropine sulfate injection","J0461","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.26",,,,,,,"fee schedule","0.21","0.26",
"Atropine sulfate injection","J0461","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.21",,,,,,,"fee schedule","0.21","0.26",
"Dimecaprol injection","J0470","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","202.78",,,,,,,"fee schedule","202.78","202.78",
"Baclofen 10 mg injection","J0475","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","402.05",,,,,,,"fee schedule","402.05","602.3",
"Baclofen 10 mg injection","J0475","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","402.05",,,,,,,"fee schedule","402.05","602.3",
"Baclofen 10 mg injection","J0475","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","402.05",,,,,,,"fee schedule","402.05","602.3",
"Baclofen 10 mg injection","J0475","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","602.3",,,,,,,"fee schedule","402.05","602.3",
"Baclofen intrathecal trial","J0476","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","123.78",,,,,,,"fee schedule","123.78","166.55",
"Baclofen intrathecal trial","J0476","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","123.78",,,,,,,"fee schedule","123.78","166.55",
"Baclofen intrathecal trial","J0476","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","123.78",,,,,,,"fee schedule","123.78","166.55",
"Baclofen intrathecal trial","J0476","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","166.55",,,,,,,"fee schedule","123.78","166.55",
"Basiliximab","J0480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10781.61",,,,,,,"fee schedule","10781.61","12902.18",
"Basiliximab","J0480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10781.61",,,,,,,"fee schedule","10781.61","12902.18",
"Basiliximab","J0480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10781.61",,,,,,,"fee schedule","10781.61","12902.18",
"Basiliximab","J0480","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12902.18",,,,,,,"fee schedule","10781.61","12902.18",
"Belatacept injection","J0485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","11.62",,,,,,,"fee schedule","8.95","12.81",
"Belatacept injection","J0485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11.74",,,,,,,"fee schedule","8.95","12.81",
"Belatacept injection","J0485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.95",,,,,,,"fee schedule","8.95","12.81",
"Belatacept injection","J0485","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.81",,,,,,,"fee schedule","8.95","12.81",
"Belatacept injection","J0485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.95",,,,,,,"fee schedule","8.95","12.81",
"Belatacept injection","J0485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.95",,,,,,,"fee schedule","8.95","12.81",
"Belimumab injection","J0490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","144.98",,,,,,,"fee schedule","126.43","154.27",
"Belimumab injection","J0490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","143.55",,,,,,,"fee schedule","126.43","154.27",
"Belimumab injection","J0490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","126.43",,,,,,,"fee schedule","126.43","154.27",
"Belimumab injection","J0490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","126.43",,,,,,,"fee schedule","126.43","154.27",
"Belimumab injection","J0490","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","126.43",,,,,,,"fee schedule","126.43","154.27",
"Belimumab injection","J0490","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","154.27",,,,,,,"fee schedule","126.43","154.27",
"Inj anifrolumab-fnia 1mg","J0491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","40.89",,,,,,,"fee schedule","40.89","40.89",
"Inj anifrolumab-fnia 1mg","J0491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","40.89",,,,,,,"fee schedule","40.89","40.89",
"Inj anifrolumab-fnia 1mg","J0491","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","40.89",,,,,,,"fee schedule","40.89","40.89",
"Dicyclomine injection","J0500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","29.57",,,,,,,"fee schedule","29.57","154.02",
"Dicyclomine injection","J0500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","29.57",,,,,,,"fee schedule","29.57","154.02",
"Dicyclomine injection","J0500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","29.57",,,,,,,"fee schedule","29.57","154.02",
"Dicyclomine injection","J0500","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","154.02",,,,,,,"fee schedule","29.57","154.02",
"Inj benztropine mesylate","J0515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","38.56",,,,,,,"fee schedule","38.56","58.53",
"Inj benztropine mesylate","J0515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","38.56",,,,,,,"fee schedule","38.56","58.53",
"Inj benztropine mesylate","J0515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","38.56",,,,,,,"fee schedule","38.56","58.53",
"Inj benztropine mesylate","J0515","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","58.53",,,,,,,"fee schedule","38.56","58.53",
"Inj., benralizumab, 1 mg","J0517","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","530.27",,,,,,,"fee schedule","375.59","576.72",
"Inj., benralizumab, 1 mg","J0517","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","375.59",,,,,,,"fee schedule","375.59","576.72",
"Inj., benralizumab, 1 mg","J0517","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","525.01",,,,,,,"fee schedule","375.59","576.72",
"Inj., benralizumab, 1 mg","J0517","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","375.59",,,,,,,"fee schedule","375.59","576.72",
"Inj., benralizumab, 1 mg","J0517","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","375.59",,,,,,,"fee schedule","375.59","576.72",
"Inj., benralizumab, 1 mg","J0517","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","576.72",,,,,,,"fee schedule","375.59","576.72",
"PenG benzathine/procaine inj","J0558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","39.95",,,,,,,"fee schedule","36.65","39.95",
"PenG benzathine/procaine inj","J0558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","39.95",,,,,,,"fee schedule","36.65","39.95",
"PenG benzathine/procaine inj","J0558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","39.95",,,,,,,"fee schedule","36.65","39.95",
"PenG benzathine/procaine inj","J0558","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","36.65",,,,,,,"fee schedule","36.65","39.95",
"Penicillin g benzathine inj","J0561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","62.06",,,,,,,"fee schedule","46.9","62.06",
"Penicillin g benzathine inj","J0561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","62.06",,,,,,,"fee schedule","46.9","62.06",
"Penicillin g benzathine inj","J0561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","62.06",,,,,,,"fee schedule","46.9","62.06",
"Penicillin g benzathine inj","J0561","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","46.9",,,,,,,"fee schedule","46.9","62.06",
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","91.7",,,,,,,"fee schedule","91.7","134.8",
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","91.7",,,,,,,"fee schedule","91.7","134.8",
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","91.7",,,,,,,"fee schedule","91.7","134.8",
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","134.8",,,,,,,"fee schedule","91.7","134.8",
"Inj., cerliponase alfa 1 mg","J0567","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","316.96",,,,,,,"fee schedule","316.96","316.96",
"Buprenorphine oral 1mg","J0571","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.38",,,,,,,"fee schedule","5.38","5.38",
"Bupren/nal up to 3mg bupreno","J0572","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","25.59",,,,,,,"fee schedule","25.59","25.59",
"Bupren/nal 3.1 to 6mg bupren","J0573","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","38.37",,,,,,,"fee schedule","38.37","38.37",
"Bupren/nal 6.1 to 10mg bupre","J0574","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","42.59",,,,,,,"fee schedule","42.59","42.59",
"Bupren/nal over 10mg bupreno","J0575","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","61.19",,,,,,,"fee schedule","61.19","61.19",
"Inj, brixadi, 7 days or less","J0577","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","978.43",,,,,,,"fee schedule","978.43","978.43",
"Inj, brixadi, 7 days or less","J0577","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","978.43",,,,,,,"fee schedule","978.43","978.43",
"Inj, brixadi, 7 days or less","J0577","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","978.43",,,,,,,"fee schedule","978.43","978.43",
"Inj brixadi, more than 7 day","J0578","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3913.71",,,,,,,"fee schedule","3913.71","3913.71",
"Inj brixadi, more than 7 day","J0578","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3913.71",,,,,,,"fee schedule","3913.71","3913.71",
"Inj brixadi, more than 7 day","J0578","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3913.71",,,,,,,"fee schedule","3913.71","3913.71",
"Bivalirudin","J0583","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.35",,,,,,,"fee schedule","0.35","2.12",
"Bivalirudin","J0583","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.35",,,,,,,"fee schedule","0.35","2.12",
"Bivalirudin","J0583","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.35",,,,,,,"fee schedule","0.35","2.12",
"Bivalirudin","J0583","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.12",,,,,,,"fee schedule","0.35","2.12",
"Injection, burosumab-twza 1m","J0584","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1080.41",,,,,,,"fee schedule","1080.41","1198.07",
"Injection, burosumab-twza 1m","J0584","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1080.41",,,,,,,"fee schedule","1080.41","1198.07",
"Injection, burosumab-twza 1m","J0584","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1080.41",,,,,,,"fee schedule","1080.41","1198.07",
"Injection, burosumab-twza 1m","J0584","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1198.07",,,,,,,"fee schedule","1080.41","1198.07",
"Injection,onabotulinumtoxina","J0585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","18.78",,,,,,,"fee schedule","14.9","20.72",
"Injection,onabotulinumtoxina","J0585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","18.58",,,,,,,"fee schedule","14.9","20.72",
"Injection,onabotulinumtoxina","J0585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14.9",,,,,,,"fee schedule","14.9","20.72",
"Injection,onabotulinumtoxina","J0585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14.9",,,,,,,"fee schedule","14.9","20.72",
"Injection,onabotulinumtoxina","J0585","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14.9",,,,,,,"fee schedule","14.9","20.72",
"Injection,onabotulinumtoxina","J0585","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","20.72",,,,,,,"fee schedule","14.9","20.72",
"Abobotulinumtoxina","J0586","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","25.6",,,,,,,"fee schedule","20.8","28.48",
"Abobotulinumtoxina","J0586","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20.8",,,,,,,"fee schedule","20.8","28.48",
"Abobotulinumtoxina","J0586","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20.8",,,,,,,"fee schedule","20.8","28.48",
"Abobotulinumtoxina","J0586","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","25.36",,,,,,,"fee schedule","20.8","28.48",
"Abobotulinumtoxina","J0586","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","20.8",,,,,,,"fee schedule","20.8","28.48",
"Abobotulinumtoxina","J0586","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","28.48",,,,,,,"fee schedule","20.8","28.48",
"Inj, rimabotulinumtoxinb","J0587","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","36.68",,,,,,,"fee schedule","29.89","40.65",
"Inj, rimabotulinumtoxinb","J0587","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","37.05",,,,,,,"fee schedule","29.89","40.65",
"Inj, rimabotulinumtoxinb","J0587","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","29.89",,,,,,,"fee schedule","29.89","40.65",
"Inj, rimabotulinumtoxinb","J0587","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","29.89",,,,,,,"fee schedule","29.89","40.65",
"Inj, rimabotulinumtoxinb","J0587","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","29.89",,,,,,,"fee schedule","29.89","40.65",
"Inj, rimabotulinumtoxinb","J0587","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","40.65",,,,,,,"fee schedule","29.89","40.65",
"Incobotulinumtoxin a","J0588","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","15.66",,,,,,,"fee schedule","12.26","17.06",
"Incobotulinumtoxin a","J0588","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","15.49",,,,,,,"fee schedule","12.26","17.06",
"Incobotulinumtoxin a","J0588","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17.06",,,,,,,"fee schedule","12.26","17.06",
"Incobotulinumtoxin a","J0588","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12.26",,,,,,,"fee schedule","12.26","17.06",
"Incobotulinumtoxin a","J0588","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12.26",,,,,,,"fee schedule","12.26","17.06",
"Incobotulinumtoxin a","J0588","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12.26",,,,,,,"fee schedule","12.26","17.06",
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.88",,,,,,,"fee schedule","6.88","6.88",
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.88",,,,,,,"fee schedule","6.88","6.88",
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.88",,,,,,,"fee schedule","6.88","6.88",
"Buprenorphine hydrochloride","J0592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.61",,,,,,,"fee schedule","9.61","16.1",
"Buprenorphine hydrochloride","J0592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.61",,,,,,,"fee schedule","9.61","16.1",
"Buprenorphine hydrochloride","J0592","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.61",,,,,,,"fee schedule","9.61","16.1",
"Buprenorphine hydrochloride","J0592","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16.1",,,,,,,"fee schedule","9.61","16.1",
"Inj., lanadelumab-flyo, 1 mg","J0593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","195.04",,,,,,,"fee schedule","195.04","258.65",
"Inj., lanadelumab-flyo, 1 mg","J0593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","195.04",,,,,,,"fee schedule","195.04","258.65",
"Inj., lanadelumab-flyo, 1 mg","J0593","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","195.04",,,,,,,"fee schedule","195.04","258.65",
"Inj., lanadelumab-flyo, 1 mg","J0593","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","258.65",,,,,,,"fee schedule","195.04","258.65",
"Busulfan injection","J0594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.35",,,,,,,"fee schedule","3.35","14.8",
"Busulfan injection","J0594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.35",,,,,,,"fee schedule","3.35","14.8",
"Busulfan injection","J0594","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.35",,,,,,,"fee schedule","3.35","14.8",
"Busulfan injection","J0594","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14.8",,,,,,,"fee schedule","3.35","14.8",
"Butorphanol tartrate 1 mg","J0595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.79",,,,,,,"fee schedule","8.58","10.79",
"Butorphanol tartrate 1 mg","J0595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.79",,,,,,,"fee schedule","8.58","10.79",
"Butorphanol tartrate 1 mg","J0595","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.79",,,,,,,"fee schedule","8.58","10.79",
"Butorphanol tartrate 1 mg","J0595","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.58",,,,,,,"fee schedule","8.58","10.79",
"Injection, ruconest","J0596","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","89.71",,,,,,,"fee schedule","79.93","96.11",
"Injection, ruconest","J0596","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","88.82",,,,,,,"fee schedule","79.93","96.11",
"Injection, ruconest","J0596","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","79.93",,,,,,,"fee schedule","79.93","96.11",
"Injection, ruconest","J0596","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","79.93",,,,,,,"fee schedule","79.93","96.11",
"Injection, ruconest","J0596","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","79.93",,,,,,,"fee schedule","79.93","96.11",
"Injection, ruconest","J0596","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","96.11",,,,,,,"fee schedule","79.93","96.11",
"C-1 esterase, berinert","J0597","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","166.53",,,,,,,"fee schedule","166.21","173.83",
"C-1 esterase, berinert","J0597","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","166.21",,,,,,,"fee schedule","166.21","173.83",
"C-1 esterase, berinert","J0597","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","168.18",,,,,,,"fee schedule","166.21","173.83",
"C-1 esterase, berinert","J0597","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","166.21",,,,,,,"fee schedule","166.21","173.83",
"C-1 esterase, berinert","J0597","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","166.21",,,,,,,"fee schedule","166.21","173.83",
"C-1 esterase, berinert","J0597","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","173.83",,,,,,,"fee schedule","166.21","173.83",
"C-1 esterase, cinryze","J0598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","172.9",,,,,,,"fee schedule","146.92","190.3",
"C-1 esterase, cinryze","J0598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","174.63",,,,,,,"fee schedule","146.92","190.3",
"C-1 esterase, cinryze","J0598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","146.92",,,,,,,"fee schedule","146.92","190.3",
"C-1 esterase, cinryze","J0598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","146.92",,,,,,,"fee schedule","146.92","190.3",
"C-1 esterase, cinryze","J0598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","146.92",,,,,,,"fee schedule","146.92","190.3",
"C-1 esterase, cinryze","J0598","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","190.3",,,,,,,"fee schedule","146.92","190.3",
"Inj., haegarda 10 units","J0599","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","32.78",,,,,,,"fee schedule","32.78","32.78",
"Edetate calcium disodium inj","J0600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14858.06",,,,,,,"fee schedule","14858.06","18967.15",
"Edetate calcium disodium inj","J0600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14858.06",,,,,,,"fee schedule","14858.06","18967.15",
"Edetate calcium disodium inj","J0600","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14858.06",,,,,,,"fee schedule","14858.06","18967.15",
"Edetate calcium disodium inj","J0600","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18967.15",,,,,,,"fee schedule","14858.06","18967.15",
"Cinacalcet, esrd on dialysis","J0604","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.49",,,,,,,"fee schedule","3.49","3.49",
"Inj, etelcalcetide, 0.1 mg","J0606","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.9",,,,,,,"fee schedule","7.9","7.9",
"Calcium glucon (fresenius)","J0612","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.15",,,,,,,"fee schedule","0.11","0.15",
"Calcium glucon (fresenius)","J0612","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.11",,,,,,,"fee schedule","0.11","0.15",
"Calcium glucon (fresenius)","J0612","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.11",,,,,,,"fee schedule","0.11","0.15",
"Calcium glucon (fresenius)","J0612","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.11",,,,,,,"fee schedule","0.11","0.15",
"Calcium glucon (wg critical)","J0613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.17",,,,,,,"fee schedule","0.17","0.17",
"Calcium glucon (wg critical)","J0613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.17",,,,,,,"fee schedule","0.17","0.17",
"Calcium glucon (wg critical)","J0613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.17",,,,,,,"fee schedule","0.17","0.17",
"Calcium glycer & lact/10 ML","J0620","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","41.61",,,,,,,"fee schedule","41.61","41.61",
"Calcitonin salmon injection","J0630","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8996.21",,,,,,,"fee schedule","8996.21","8996.21",
"Inj calcitriol per 0.1 mcg","J0636","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.6",,,,,,,"fee schedule","2.6","2.6",
"Caspofungin acetate","J0637","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.67",,,,,,,"fee schedule","7.67","22.16",
"Caspofungin acetate","J0637","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.67",,,,,,,"fee schedule","7.67","22.16",
"Caspofungin acetate","J0637","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.67",,,,,,,"fee schedule","7.67","22.16",
"Caspofungin acetate","J0637","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","22.16",,,,,,,"fee schedule","7.67","22.16",
"Canakinumab injection","J0638","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","350.6",,,,,,,"fee schedule","314.08","376.33",
"Canakinumab injection","J0638","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","314.08",,,,,,,"fee schedule","314.08","376.33",
"Canakinumab injection","J0638","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","347.14",,,,,,,"fee schedule","314.08","376.33",
"Canakinumab injection","J0638","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","314.08",,,,,,,"fee schedule","314.08","376.33",
"Canakinumab injection","J0638","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","314.08",,,,,,,"fee schedule","314.08","376.33",
"Canakinumab injection","J0638","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","376.33",,,,,,,"fee schedule","314.08","376.33",
"Leucovorin calcium injection","J0640","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.08",,,,,,,"fee schedule","8.08","10.29",
"Leucovorin calcium injection","J0640","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.08",,,,,,,"fee schedule","8.08","10.29",
"Leucovorin calcium injection","J0640","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.08",,,,,,,"fee schedule","8.08","10.29",
"Leucovorin calcium injection","J0640","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.29",,,,,,,"fee schedule","8.08","10.29",
"Levoleucovorin injection","J0641","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.04",,,,,,,"fee schedule","0.04","0.4",
"Levoleucovorin injection","J0641","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.4",,,,,,,"fee schedule","0.04","0.4",
"Levoleucovorin injection","J0641","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.04",,,,,,,"fee schedule","0.04","0.4",
"Levoleucovorin injection","J0641","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.04",,,,,,,"fee schedule","0.04","0.4",
"Injection, khapzory, 0.5 mg","J0642","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.7",,,,,,,"fee schedule","2.7","6.57",
"Injection, khapzory, 0.5 mg","J0642","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.7",,,,,,,"fee schedule","2.7","6.57",
"Injection, khapzory, 0.5 mg","J0642","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.7",,,,,,,"fee schedule","2.7","6.57",
"Injection, khapzory, 0.5 mg","J0642","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.57",,,,,,,"fee schedule","2.7","6.57",
"Inj, levothyroxine nos 10mcg","J0650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.7",,,,,,,"fee schedule","16.7","16.7",
"Inj, levothyroxine nos 10mcg","J0650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.7",,,,,,,"fee schedule","16.7","16.7",
"Inj, levothyroxine nos 10mcg","J0650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.7",,,,,,,"fee schedule","16.7","16.7",
"Inj, levothyroxine, freskabi","J0651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14.72",,,,,,,"fee schedule","14.72","14.72",
"Inj, levothyroxine, freskabi","J0651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14.72",,,,,,,"fee schedule","14.72","14.72",
"Inj, levothyroxine, freskabi","J0651","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14.72",,,,,,,"fee schedule","14.72","14.72",
"Inj, levothyroxine, hikma","J0652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.81",,,,,,,"fee schedule","11.81","11.81",
"Inj, levothyroxine, hikma","J0652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.81",,,,,,,"fee schedule","11.81","11.81",
"Inj, levothyroxine, hikma","J0652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.81",,,,,,,"fee schedule","11.81","11.81",
"Inj, bupivacaine, nos, 0.5mg","J0665","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.02",,,,,,,"fee schedule","0.02","0.02",
"Inj, bupivacaine, nos, 0.5mg","J0665","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.02",,,,,,,"fee schedule","0.02","0.02",
"Inj, bupivacaine, nos, 0.5mg","J0665","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.02",,,,,,,"fee schedule","0.02","0.02",
"Inj, bupivacaine liposome","J0666","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.27",,,,,,,"fee schedule","3.27","3.27",
"Inj, bupivacaine liposome","J0666","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.27",,,,,,,"fee schedule","3.27","3.27",
"Inj, bupivacaine liposome","J0666","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.27",,,,,,,"fee schedule","3.27","3.27",
"Inj mepivacaine HCL/10 ml","J0670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.34",,,,,,,"fee schedule","8.34","9.23",
"Inj mepivacaine HCL/10 ml","J0670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.34",,,,,,,"fee schedule","8.34","9.23",
"Inj mepivacaine HCL/10 ml","J0670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.34",,,,,,,"fee schedule","8.34","9.23",
"Inj mepivacaine HCL/10 ml","J0670","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.23",,,,,,,"fee schedule","8.34","9.23",
"Inj cefazolin (wg crit care)","J0687","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.24",,,,,,,"fee schedule","2.24","2.24",
"Inj cefazolin (wg crit care)","J0687","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.24",,,,,,,"fee schedule","2.24","2.24",
"Inj cefazolin (wg crit care)","J0687","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.24",,,,,,,"fee schedule","2.24","2.24",
"Inj cefazolin sodium, hikma","J0688","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.26",,,,,,,"fee schedule","2.26","2.26",
"Inj cefazolin sodium, hikma","J0688","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.26",,,,,,,"fee schedule","2.26","2.26",
"Inj cefazolin sodium, hikma","J0688","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.26",,,,,,,"fee schedule","2.26","2.26",
"Inj cefazolin sodium, baxter","J0689","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.86",,,,,,,"fee schedule","2.86","2.86",
"Inj cefazolin sodium, baxter","J0689","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.86",,,,,,,"fee schedule","2.86","2.86",
"Inj cefazolin sodium, baxter","J0689","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.86",,,,,,,"fee schedule","2.86","2.86",
"Cefazolin sodium injection","J0690","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.9",,,,,,,"fee schedule","1.9","2.78",
"Cefazolin sodium injection","J0690","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.9",,,,,,,"fee schedule","1.9","2.78",
"Cefazolin sodium injection","J0690","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.9",,,,,,,"fee schedule","1.9","2.78",
"Cefazolin sodium injection","J0690","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.78",,,,,,,"fee schedule","1.9","2.78",
"Inj lefamulin 1 mg","J0691","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.44",,,,,,,"fee schedule","2.44","2.44",
"Cefepime hcl for injection","J0692","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.76",,,,,,,"fee schedule","2.76","6.18",
"Cefepime hcl for injection","J0692","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.76",,,,,,,"fee schedule","2.76","6.18",
"Cefepime hcl for injection","J0692","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.76",,,,,,,"fee schedule","2.76","6.18",
"Cefepime hcl for injection","J0692","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.18",,,,,,,"fee schedule","2.76","6.18",
"Cefoxitin sodium injection","J0694","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.52",,,,,,,"fee schedule","11.52","24.87",
"Cefoxitin sodium injection","J0694","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.52",,,,,,,"fee schedule","11.52","24.87",
"Cefoxitin sodium injection","J0694","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.52",,,,,,,"fee schedule","11.52","24.87",
"Cefoxitin sodium injection","J0694","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","24.87",,,,,,,"fee schedule","11.52","24.87",
"Inj ceftolozane tazobactam","J0695","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18.49",,,,,,,"fee schedule","18.49","19.93",
"Inj ceftolozane tazobactam","J0695","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18.49",,,,,,,"fee schedule","18.49","19.93",
"Inj ceftolozane tazobactam","J0695","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18.49",,,,,,,"fee schedule","18.49","19.93",
"Inj ceftolozane tazobactam","J0695","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19.93",,,,,,,"fee schedule","18.49","19.93",
"Ceftriaxone sodium injection","J0696","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.13",,,,,,,"fee schedule","1.13","1.79",
"Ceftriaxone sodium injection","J0696","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.13",,,,,,,"fee schedule","1.13","1.79",
"Ceftriaxone sodium injection","J0696","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.13",,,,,,,"fee schedule","1.13","1.79",
"Ceftriaxone sodium injection","J0696","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.79",,,,,,,"fee schedule","1.13","1.79",
"Sterile cefuroxime injection","J0697","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.63",,,,,,,"fee schedule","4.63","7.21",
"Sterile cefuroxime injection","J0697","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.63",,,,,,,"fee schedule","4.63","7.21",
"Sterile cefuroxime injection","J0697","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.63",,,,,,,"fee schedule","4.63","7.21",
"Sterile cefuroxime injection","J0697","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.21",,,,,,,"fee schedule","4.63","7.21",
"Cefotaxime sodium injection","J0698","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.9",,,,,,,"fee schedule","7.9","7.9",
"Inj, cefiderocol, 10 mg","J0699","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.25",,,,,,,"fee schedule","5.25","5.25",
"Inj, cefiderocol, 10 mg","J0699","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.25",,,,,,,"fee schedule","5.25","5.25",
"Inj, cefiderocol, 10 mg","J0699","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.25",,,,,,,"fee schedule","5.25","5.25",
"Inj. cefepime hcl (baxter)","J0701","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13.35",,,,,,,"fee schedule","13.35","13.35",
"Inj. cefepime hcl (baxter)","J0701","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13.35",,,,,,,"fee schedule","13.35","13.35",
"Inj. cefepime hcl (baxter)","J0701","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13.35",,,,,,,"fee schedule","13.35","13.35",
"Betamethasone acet&sod phosp","J0702","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15.75",,,,,,,"fee schedule","15.75","24.82",
"Betamethasone acet&sod phosp","J0702","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15.75",,,,,,,"fee schedule","15.75","24.82",
"Betamethasone acet&sod phosp","J0702","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15.75",,,,,,,"fee schedule","15.75","24.82",
"Betamethasone acet&sod phosp","J0702","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","24.82",,,,,,,"fee schedule","15.75","24.82",
"Inj, cefepime hcl (b braun)","J0703","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.6",,,,,,,"fee schedule","11.6","11.6",
"Inj, cefepime hcl (b braun)","J0703","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.6",,,,,,,"fee schedule","11.6","11.6",
"Inj, cefepime hcl (b braun)","J0703","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.6",,,,,,,"fee schedule","11.6","11.6",
"Caffeine citrate injection","J0706","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.92",,,,,,,"fee schedule","8.92","8.92",
"Ceftaroline fosamil inj","J0712","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.18",,,,,,,"fee schedule","9.18","10.79",
"Ceftaroline fosamil inj","J0712","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.18",,,,,,,"fee schedule","9.18","10.79",
"Ceftaroline fosamil inj","J0712","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.18",,,,,,,"fee schedule","9.18","10.79",
"Ceftaroline fosamil inj","J0712","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.79",,,,,,,"fee schedule","9.18","10.79",
"Inj ceftazidime per 500 mg","J0713","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.68",,,,,,,"fee schedule","3.68","6.7",
"Inj ceftazidime per 500 mg","J0713","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.68",,,,,,,"fee schedule","3.68","6.7",
"Inj ceftazidime per 500 mg","J0713","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.68",,,,,,,"fee schedule","3.68","6.7",
"Inj ceftazidime per 500 mg","J0713","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.7",,,,,,,"fee schedule","3.68","6.7",
"Ceftazidime and avibactam","J0714","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","231.14",,,,,,,"fee schedule","231.14","312.08",
"Ceftazidime and avibactam","J0714","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","231.14",,,,,,,"fee schedule","231.14","312.08",
"Ceftazidime and avibactam","J0714","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","231.14",,,,,,,"fee schedule","231.14","312.08",
"Ceftazidime and avibactam","J0714","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","312.08",,,,,,,"fee schedule","231.14","312.08",
"Centruroides immune f(ab)","J0716","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16349.81",,,,,,,"fee schedule","16349.81","16349.81",
"Certolizumab pegol inj 1mg","J0717","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.16",,,,,,,"fee schedule","9.16","27.08",
"Certolizumab pegol inj 1mg","J0717","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.16",,,,,,,"fee schedule","9.16","27.08",
"Certolizumab pegol inj 1mg","J0717","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.16",,,,,,,"fee schedule","9.16","27.08",
"Certolizumab pegol inj 1mg","J0717","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","27.08",,,,,,,"fee schedule","9.16","27.08",
"Chloramphenicol sodium injec","J0720","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","108.11",,,,,,,"fee schedule","108.11","108.11",
"Chorionic gonadotropin/1000u","J0725","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","41.98",,,,,,,"fee schedule","41.98","72.04",
"Chorionic gonadotropin/1000u","J0725","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41.98",,,,,,,"fee schedule","41.98","72.04",
"Chorionic gonadotropin/1000u","J0725","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41.98",,,,,,,"fee schedule","41.98","72.04",
"Chorionic gonadotropin/1000u","J0725","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","72.04",,,,,,,"fee schedule","41.98","72.04",
"Clonidine hydrochloride","J0735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","37.26",,,,,,,"fee schedule","37.26","44.17",
"Clonidine hydrochloride","J0735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","37.26",,,,,,,"fee schedule","37.26","44.17",
"Clonidine hydrochloride","J0735","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","37.26",,,,,,,"fee schedule","37.26","44.17",
"Clonidine hydrochloride","J0735","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","44.17",,,,,,,"fee schedule","37.26","44.17",
"Inj, clindamycin phosp 300mg","J0736","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.71",,,,,,,"fee schedule","3.71","3.71",
"Inj, clindamycin phosp 300mg","J0736","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.71",,,,,,,"fee schedule","3.71","3.71",
"Inj, clindamycin phosp 300mg","J0736","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.71",,,,,,,"fee schedule","3.71","3.71",
"Inj, clindamycin (baxter)","J0737","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.81",,,,,,,"fee schedule","5.81","5.81",
"Inj, clindamycin (baxter)","J0737","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.81",,,,,,,"fee schedule","5.81","5.81",
"Inj, clindamycin (baxter)","J0737","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.81",,,,,,,"fee schedule","5.81","5.81",
"Injection, cabotegravir 1 mg","J0739","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15.84",,,,,,,"fee schedule","15.84","15.84",
"Injection, cabotegravir 1 mg","J0739","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15.84",,,,,,,"fee schedule","15.84","15.84",
"Injection, cabotegravir 1 mg","J0739","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15.84",,,,,,,"fee schedule","15.84","15.84",
"Cidofovir injection","J0740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1200.2",,,,,,,"fee schedule","1200.2","2071.76",
"Cidofovir injection","J0740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1200.2",,,,,,,"fee schedule","1200.2","2071.76",
"Cidofovir injection","J0740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1200.2",,,,,,,"fee schedule","1200.2","2071.76",
"Cidofovir injection","J0740","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2071.76",,,,,,,"fee schedule","1200.2","2071.76",
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","53.2",,,,,,,"fee schedule","46.43","53.2",
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","53.2",,,,,,,"fee schedule","46.43","53.2",
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","53.2",,,,,,,"fee schedule","46.43","53.2",
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","46.43",,,,,,,"fee schedule","46.43","53.2",
"Inj imip 4 cilas 4 releb 2mg","J0742","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.74",,,,,,,"fee schedule","5.74","5.74",
"Inj imip 4 cilas 4 releb 2mg","J0742","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.74",,,,,,,"fee schedule","5.74","5.74",
"Inj imip 4 cilas 4 releb 2mg","J0742","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.74",,,,,,,"fee schedule","5.74","5.74",
"Cilastatin sodium injection","J0743","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","20.46",,,,,,,"fee schedule","16.88","20.46",
"Cilastatin sodium injection","J0743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.88",,,,,,,"fee schedule","16.88","20.46",
"Cilastatin sodium injection","J0743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.88",,,,,,,"fee schedule","16.88","20.46",
"Cilastatin sodium injection","J0743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.88",,,,,,,"fee schedule","16.88","20.46",
"Ciprofloxacin iv","J0744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.83",,,,,,,"fee schedule","3.98","4.83",
"Ciprofloxacin iv","J0744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.83",,,,,,,"fee schedule","3.98","4.83",
"Ciprofloxacin iv","J0744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.83",,,,,,,"fee schedule","3.98","4.83",
"Ciprofloxacin iv","J0744","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.98",,,,,,,"fee schedule","3.98","4.83",
"Inj codeine phosphate /30 MG","J0745","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.66",,,,,,,"fee schedule","3.66","3.66",
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.94",,,,,,,"fee schedule","2.94","2.94",
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.94",,,,,,,"fee schedule","2.94","2.94",
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.94",,,,,,,"fee schedule","2.94","2.94",
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","163.93",,,,,,,"fee schedule","163.93","163.93",
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","163.93",,,,,,,"fee schedule","163.93","163.93",
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","163.93",,,,,,,"fee schedule","163.93","163.93",
"Colistimethate sodium inj","J0770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","27.47",,,,,,,"fee schedule","27.47","61.57",
"Colistimethate sodium inj","J0770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","27.47",,,,,,,"fee schedule","27.47","61.57",
"Colistimethate sodium inj","J0770","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","27.47",,,,,,,"fee schedule","27.47","61.57",
"Colistimethate sodium inj","J0770","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","61.57",,,,,,,"fee schedule","27.47","61.57",
"Collagenase, clost hist inj","J0775","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","168.76",,,,,,,"fee schedule","168.76","170.88",
"Collagenase, clost hist inj","J0775","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","168.76",,,,,,,"fee schedule","168.76","170.88",
"Collagenase, clost hist inj","J0775","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","168.76",,,,,,,"fee schedule","168.76","170.88",
"Collagenase, clost hist inj","J0775","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","170.88",,,,,,,"fee schedule","168.76","170.88",
"Prochlorperazine injection","J0780","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.71",,,,,,,"fee schedule","6.71","26",
"Prochlorperazine injection","J0780","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.71",,,,,,,"fee schedule","6.71","26",
"Prochlorperazine injection","J0780","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.71",,,,,,,"fee schedule","6.71","26",
"Prochlorperazine injection","J0780","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","26",,,,,,,"fee schedule","6.71","26",
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","297.85",,,,,,,"fee schedule","82.32","297.85",
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","297.85",,,,,,,"fee schedule","82.32","297.85",
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","297.85",,,,,,,"fee schedule","82.32","297.85",
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","82.32",,,,,,,"fee schedule","82.32","297.85",
"Corticorelin ovine triflutal","J0795","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","31.73",,,,,,,"fee schedule","31.73","31.73",
"Inj. acthar gel to 40 units","J0801","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8954.89",,,,,,,"fee schedule","8954.89","8954.89",
"Inj. acthar gel to 40 units","J0801","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8954.89",,,,,,,"fee schedule","8954.89","8954.89",
"Inj. acthar gel to 40 units","J0801","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8954.89",,,,,,,"fee schedule","8954.89","8954.89",
"Inj. (ani), up to 40 units","J0802","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7924.84",,,,,,,"fee schedule","7924.84","7924.84",
"Inj. (ani), up to 40 units","J0802","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7924.84",,,,,,,"fee schedule","7924.84","7924.84",
"Inj. (ani), up to 40 units","J0802","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7924.84",,,,,,,"fee schedule","7924.84","7924.84",
"Cosyntropin cortrosyn inj","J0834","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","76.81",,,,,,,"fee schedule","76.81","139.59",
"Cosyntropin cortrosyn inj","J0834","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","76.81",,,,,,,"fee schedule","76.81","139.59",
"Cosyntropin cortrosyn inj","J0834","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","76.81",,,,,,,"fee schedule","76.81","139.59",
"Cosyntropin cortrosyn inj","J0834","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","139.59",,,,,,,"fee schedule","76.81","139.59",
"Crotalidae poly immune fab","J0840","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4038.37",,,,,,,"fee schedule","4038.37","10763.19",
"Crotalidae poly immune fab","J0840","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4038.37",,,,,,,"fee schedule","4038.37","10763.19",
"Crotalidae poly immune fab","J0840","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4038.37",,,,,,,"fee schedule","4038.37","10763.19",
"Crotalidae poly immune fab","J0840","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10763.19",,,,,,,"fee schedule","4038.37","10763.19",
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2400.16",,,,,,,"fee schedule","2400.16","4275.02",
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2400.16",,,,,,,"fee schedule","2400.16","4275.02",
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2400.16",,,,,,,"fee schedule","2400.16","4275.02",
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4275.02",,,,,,,"fee schedule","2400.16","4275.02",
"Cytomegalovirus imm IV /vial","J0850","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4167.62",,,,,,,"fee schedule","4167.62","4525.51",
"Cytomegalovirus imm IV /vial","J0850","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4167.62",,,,,,,"fee schedule","4167.62","4525.51",
"Cytomegalovirus imm IV /vial","J0850","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4167.62",,,,,,,"fee schedule","4167.62","4525.51",
"Cytomegalovirus imm IV /vial","J0850","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4525.51",,,,,,,"fee schedule","4167.62","4525.51",
"Injection, imetelstat, 1 mg","J0870","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","127.67",,,,,,,"fee schedule","127.67","127.67",
"Injection, imetelstat, 1 mg","J0870","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","127.67",,,,,,,"fee schedule","127.67","127.67",
"Injection, imetelstat, 1 mg","J0870","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","127.67",,,,,,,"fee schedule","127.67","127.67",
"Daptomycin (xellia) unrefrig","J0872","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.12",,,,,,,"fee schedule","0.12","0.12",
"Daptomycin (xellia) unrefrig","J0872","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.12",,,,,,,"fee schedule","0.12","0.12",
"Daptomycin (xellia) unrefrig","J0872","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.12",,,,,,,"fee schedule","0.12","0.12",
"Inj, daptomycin (xellia)","J0873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.08",,,,,,,"fee schedule","0.08","0.08",
"Inj, daptomycin (xellia)","J0873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.08",,,,,,,"fee schedule","0.08","0.08",
"Inj, daptomycin (xellia)","J0873","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.08",,,,,,,"fee schedule","0.08","0.08",
"Inj, daptomycin (baxter)","J0874","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.15",,,,,,,"fee schedule","0.15","0.15",
"Inj, daptomycin (baxter)","J0874","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.15",,,,,,,"fee schedule","0.15","0.15",
"Inj, daptomycin (baxter)","J0874","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.15",,,,,,,"fee schedule","0.15","0.15",
"Injection, dalbavancin","J0875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","35.8",,,,,,,"fee schedule","35.8","50.93",
"Injection, dalbavancin","J0875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","35.8",,,,,,,"fee schedule","35.8","50.93",
"Injection, dalbavancin","J0875","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","35.8",,,,,,,"fee schedule","35.8","50.93",
"Injection, dalbavancin","J0875","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","50.93",,,,,,,"fee schedule","35.8","50.93",
"Inj, daptomycin (hospira)","J0877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.13",,,,,,,"fee schedule","0.13","0.13",
"Inj, daptomycin (hospira)","J0877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.13",,,,,,,"fee schedule","0.13","0.13",
"Inj, daptomycin (hospira)","J0877","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.13",,,,,,,"fee schedule","0.13","0.13",
"Daptomycin injection","J0878","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.08",,,,,,,"fee schedule","0.08","0.69",
"Daptomycin injection","J0878","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.69",,,,,,,"fee schedule","0.08","0.69",
"Daptomycin injection","J0878","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.08",,,,,,,"fee schedule","0.08","0.69",
"Daptomycin injection","J0878","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.08",,,,,,,"fee schedule","0.08","0.69",
"Darbepoetin alfa, non-esrd","J0881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10.91",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, non-esrd","J0881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11.02",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, non-esrd","J0881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.71",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, non-esrd","J0881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.71",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, non-esrd","J0881","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.71",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, non-esrd","J0881","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.45",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, esrd use","J0882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","11.02",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, esrd use","J0882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","10.91",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, esrd use","J0882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.71",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, esrd use","J0882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.71",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, esrd use","J0882","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.71",,,,,,,"fee schedule","6.71","12.45",
"Darbepoetin alfa, esrd use","J0882","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.45",,,,,,,"fee schedule","6.71","12.45",
"Argatroban nonesrd use 1mg","J0883","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.19",,,,,,,"fee schedule","2.19","4.79",
"Argatroban nonesrd use 1mg","J0883","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.19",,,,,,,"fee schedule","2.19","4.79",
"Argatroban nonesrd use 1mg","J0883","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.19",,,,,,,"fee schedule","2.19","4.79",
"Argatroban nonesrd use 1mg","J0883","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.79",,,,,,,"fee schedule","2.19","4.79",
"Argatroban esrd dialysis 1mg","J0884","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.19",,,,,,,"fee schedule","2.19","4.79",
"Argatroban esrd dialysis 1mg","J0884","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.19",,,,,,,"fee schedule","2.19","4.79",
"Argatroban esrd dialysis 1mg","J0884","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.19",,,,,,,"fee schedule","2.19","4.79",
"Argatroban esrd dialysis 1mg","J0884","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.79",,,,,,,"fee schedule","2.19","4.79",
"Epoetin alfa, non-esrd","J0885","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.28",,,,,,,"fee schedule","16.28","33.97",
"Epoetin alfa, non-esrd","J0885","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.28",,,,,,,"fee schedule","16.28","33.97",
"Epoetin alfa, non-esrd","J0885","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.28",,,,,,,"fee schedule","16.28","33.97",
"Epoetin alfa, non-esrd","J0885","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","33.97",,,,,,,"fee schedule","16.28","33.97",
"Epoetin beta esrd use","J0887","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4.64",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta esrd use","J0887","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4.59",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta esrd use","J0887","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.9",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta esrd use","J0887","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.9",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta esrd use","J0887","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.9",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta esrd use","J0887","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.27",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta non esrd","J0888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4.64",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta non esrd","J0888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4.59",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta non esrd","J0888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.9",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta non esrd","J0888","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.27",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta non esrd","J0888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.9",,,,,,,"fee schedule","2.9","6.27",
"Epoetin beta non esrd","J0888","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.9",,,,,,,"fee schedule","2.9","6.27",
"Inj, decitabine (sun pharma)","J0893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.79",,,,,,,"fee schedule","1.79","1.79",
"Inj, decitabine (sun pharma)","J0893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.79",,,,,,,"fee schedule","1.79","1.79",
"Inj, decitabine (sun pharma)","J0893","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.79",,,,,,,"fee schedule","1.79","1.79",
"Decitabine injection","J0894","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.06",,,,,,,"fee schedule","4.06","15.15",
"Decitabine injection","J0894","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.06",,,,,,,"fee schedule","4.06","15.15",
"Decitabine injection","J0894","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.06",,,,,,,"fee schedule","4.06","15.15",
"Decitabine injection","J0894","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15.15",,,,,,,"fee schedule","4.06","15.15",
"Deferoxamine mesylate inj","J0895","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18.88",,,,,,,"fee schedule","18.88","28.07",
"Deferoxamine mesylate inj","J0895","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18.88",,,,,,,"fee schedule","18.88","28.07",
"Deferoxamine mesylate inj","J0895","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18.88",,,,,,,"fee schedule","18.88","28.07",
"Deferoxamine mesylate inj","J0895","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","28.07",,,,,,,"fee schedule","18.88","28.07",
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","94.86",,,,,,,"fee schedule","94.86","94.86",
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","94.86",,,,,,,"fee schedule","94.86","94.86",
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","94.86",,,,,,,"fee schedule","94.86","94.86",
"Denosumab injection","J0897","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","62.25",,,,,,,"fee schedule","61.63","65.56",
"Denosumab injection","J0897","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","63.96",,,,,,,"fee schedule","61.63","65.56",
"Denosumab injection","J0897","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","61.63",,,,,,,"fee schedule","61.63","65.56",
"Denosumab injection","J0897","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","63.96",,,,,,,"fee schedule","61.63","65.56",
"Denosumab injection","J0897","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","63.96",,,,,,,"fee schedule","61.63","65.56",
"Denosumab injection","J0897","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","65.56",,,,,,,"fee schedule","61.63","65.56",
"Argatroban nonesrd (auromed)","J0898","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.08",,,,,,,"fee schedule","3.08","3.08",
"Argatroban nonesrd (auromed)","J0898","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.08",,,,,,,"fee schedule","3.08","3.08",
"Argatroban nonesrd (auromed)","J0898","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.08",,,,,,,"fee schedule","3.08","3.08",
"Argatroban dialysis, auromed","J0899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.08",,,,,,,"fee schedule","3.08","3.08",
"Argatroban dialysis, auromed","J0899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.08",,,,,,,"fee schedule","3.08","3.08",
"Argatroban dialysis, auromed","J0899","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.08",,,,,,,"fee schedule","3.08","3.08",
"Brompheniramine maleate inj","J0945","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","1.22","1.22",
"Depo-estradiol cypionate inj","J1000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","97.34",,,,,,,"fee schedule","73.99","97.34",
"Depo-estradiol cypionate inj","J1000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","97.34",,,,,,,"fee schedule","73.99","97.34",
"Depo-estradiol cypionate inj","J1000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","97.34",,,,,,,"fee schedule","73.99","97.34",
"Depo-estradiol cypionate inj","J1000","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","73.99",,,,,,,"fee schedule","73.99","97.34",
"Inj, methylpred acetate 1 mg","J1010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.25",,,,,,,"fee schedule","0.25","0.33",
"Inj, methylpred acetate 1 mg","J1010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.25",,,,,,,"fee schedule","0.25","0.33",
"Inj, methylpred acetate 1 mg","J1010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.25",,,,,,,"fee schedule","0.25","0.33",
"Inj, methylpred acetate 1 mg","J1010","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.33",,,,,,,"fee schedule","0.25","0.33",
"Medroxyprogesterone acetate","J1050","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.9",,,,,,,"fee schedule","1.9","1.9",
"Inj testosterone cypionate","J1071","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.07",,,,,,,"fee schedule","0.07","0.11",
"Inj testosterone cypionate","J1071","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.07",,,,,,,"fee schedule","0.07","0.11",
"Inj testosterone cypionate","J1071","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.07",,,,,,,"fee schedule","0.07","0.11",
"Inj testosterone cypionate","J1071","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.11",,,,,,,"fee schedule","0.07","0.11",
"Inj dexamethasone acetate","J1094","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","1.22","1.22",
"Injection, dexamethasone 9%","J1095","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.04",,,,,,,"fee schedule","4.04","4.04",
"Dexametha opth insert 0.1 mg","J1096","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","254.56",,,,,,,"fee schedule","254.56","471.8",
"Dexametha opth insert 0.1 mg","J1096","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","254.56",,,,,,,"fee schedule","254.56","471.8",
"Dexametha opth insert 0.1 mg","J1096","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","254.56",,,,,,,"fee schedule","254.56","471.8",
"Dexametha opth insert 0.1 mg","J1096","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","471.8",,,,,,,"fee schedule","254.56","471.8",
"Phenylep ketorolac opth soln","J1097","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","358.81",,,,,,,"fee schedule","358.81","358.81",
"Dexamethasone sodium phos","J1100","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.21",,,,,,,"fee schedule","0.21","0.47",
"Dexamethasone sodium phos","J1100","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.21",,,,,,,"fee schedule","0.21","0.47",
"Dexamethasone sodium phos","J1100","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.21",,,,,,,"fee schedule","0.21","0.47",
"Dexamethasone sodium phos","J1100","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.47",,,,,,,"fee schedule","0.21","0.47",
"Inj dihydroergotamine mesylt","J1110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","197.22",,,,,,,"fee schedule","197.22","216.74",
"Inj dihydroergotamine mesylt","J1110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","197.22",,,,,,,"fee schedule","197.22","216.74",
"Inj dihydroergotamine mesylt","J1110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","197.22",,,,,,,"fee schedule","197.22","216.74",
"Inj dihydroergotamine mesylt","J1110","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","216.74",,,,,,,"fee schedule","197.22","216.74",
"Acetazolamid sodium injectio","J1120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","43.84",,,,,,,"fee schedule","43.84","49.51",
"Acetazolamid sodium injectio","J1120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","43.84",,,,,,,"fee schedule","43.84","49.51",
"Acetazolamid sodium injectio","J1120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","43.84",,,,,,,"fee schedule","43.84","49.51",
"Acetazolamid sodium injectio","J1120","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","49.51",,,,,,,"fee schedule","43.84","49.51",
"Digoxin injection","J1160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.22",,,,,,,"fee schedule","11.22","16.07",
"Digoxin injection","J1160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.22",,,,,,,"fee schedule","11.22","16.07",
"Digoxin injection","J1160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.22",,,,,,,"fee schedule","11.22","16.07",
"Digoxin injection","J1160","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16.07",,,,,,,"fee schedule","11.22","16.07",
"Digoxin immune fab (ovine)","J1162","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11427.73",,,,,,,"fee schedule","11427.73","13458.33",
"Digoxin immune fab (ovine)","J1162","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11427.73",,,,,,,"fee schedule","11427.73","13458.33",
"Digoxin immune fab (ovine)","J1162","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11427.73",,,,,,,"fee schedule","11427.73","13458.33",
"Digoxin immune fab (ovine)","J1162","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13458.33",,,,,,,"fee schedule","11427.73","13458.33",
"Phenytoin sodium injection","J1165","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.2",,,,,,,"fee schedule","1.2","2.81",
"Phenytoin sodium injection","J1165","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.2",,,,,,,"fee schedule","1.2","2.81",
"Phenytoin sodium injection","J1165","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.2",,,,,,,"fee schedule","1.2","2.81",
"Phenytoin sodium injection","J1165","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.81",,,,,,,"fee schedule","1.2","2.81",
"Inj, hydromorphone, 0.1 mg","J1171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.32",,,,,,,"fee schedule","0.32","0.32",
"Inj, hydromorphone, 0.1 mg","J1171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.32",,,,,,,"fee schedule","0.32","0.32",
"Inj, hydromorphone, 0.1 mg","J1171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.32",,,,,,,"fee schedule","0.32","0.32",
"Dexrazoxane hcl injection","J1190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","186.2",,,,,,,"fee schedule","186.2","658.82",
"Dexrazoxane hcl injection","J1190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","186.2",,,,,,,"fee schedule","186.2","658.82",
"Dexrazoxane hcl injection","J1190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","186.2",,,,,,,"fee schedule","186.2","658.82",
"Dexrazoxane hcl injection","J1190","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","658.82",,,,,,,"fee schedule","186.2","658.82",
"Diphenhydramine hcl injectio","J1200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.52",,,,,,,"fee schedule","1.52","2.85",
"Diphenhydramine hcl injectio","J1200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.52",,,,,,,"fee schedule","1.52","2.85",
"Diphenhydramine hcl injectio","J1200","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.85",,,,,,,"fee schedule","1.52","2.85",
"Diphenhydramine hcl injectio","J1200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.52",,,,,,,"fee schedule","1.52","2.85",
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","35.93",,,,,,,"fee schedule","35.93","104.77",
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","35.93",,,,,,,"fee schedule","35.93","104.77",
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","35.93",,,,,,,"fee schedule","35.93","104.77",
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","104.77",,,,,,,"fee schedule","35.93","104.77",
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","206.65",,,,,,,"fee schedule","206.65","206.65",
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","206.65",,,,,,,"fee schedule","206.65","206.65",
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","206.65",,,,,,,"fee schedule","206.65","206.65",
"Chlorothiazide sodium inj","J1205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","74.71",,,,,,,"fee schedule","74.71","202.62",
"Chlorothiazide sodium inj","J1205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","74.71",,,,,,,"fee schedule","74.71","202.62",
"Chlorothiazide sodium inj","J1205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","74.71",,,,,,,"fee schedule","74.71","202.62",
"Chlorothiazide sodium inj","J1205","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","202.62",,,,,,,"fee schedule","74.71","202.62",
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1643.87",,,,,,,"fee schedule","1643.87","2111.89",
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1643.87",,,,,,,"fee schedule","1643.87","2111.89",
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1643.87",,,,,,,"fee schedule","1643.87","2111.89",
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2111.89",,,,,,,"fee schedule","1643.87","2111.89",
"Methadone injection","J1230","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","48.1",,,,,,,"fee schedule","48.1","59.07",
"Methadone injection","J1230","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","48.1",,,,,,,"fee schedule","48.1","59.07",
"Methadone injection","J1230","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","48.1",,,,,,,"fee schedule","48.1","59.07",
"Methadone injection","J1230","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","59.07",,,,,,,"fee schedule","48.1","59.07",
"Dimenhydrinate injection","J1240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19.2",,,,,,,"fee schedule","19.2","22.11",
"Dimenhydrinate injection","J1240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19.2",,,,,,,"fee schedule","19.2","22.11",
"Dimenhydrinate injection","J1240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19.2",,,,,,,"fee schedule","19.2","22.11",
"Dimenhydrinate injection","J1240","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","22.11",,,,,,,"fee schedule","19.2","22.11",
"Dipyridamole injection","J1245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.82",,,,,,,"fee schedule","8","8.82",
"Dipyridamole injection","J1245","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8",,,,,,,"fee schedule","8","8.82",
"Dipyridamole injection","J1245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.82",,,,,,,"fee schedule","8","8.82",
"Dipyridamole injection","J1245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.82",,,,,,,"fee schedule","8","8.82",
"Inj dobutamine HCL/250 mg","J1250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18.73",,,,,,,"fee schedule","18.73","19.39",
"Inj dobutamine HCL/250 mg","J1250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18.73",,,,,,,"fee schedule","18.73","19.39",
"Inj dobutamine HCL/250 mg","J1250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18.73",,,,,,,"fee schedule","18.73","19.39",
"Inj dobutamine HCL/250 mg","J1250","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19.39",,,,,,,"fee schedule","18.73","19.39",
"Dolasetron mesylate","J1260","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","41.38",,,,,,,"fee schedule","41.38","41.38",
"Dopamine injection","J1265","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.63",,,,,,,"fee schedule","1.63","2.03",
"Dopamine injection","J1265","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.63",,,,,,,"fee schedule","1.63","2.03",
"Dopamine injection","J1265","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.03",,,,,,,"fee schedule","1.63","2.03",
"Dopamine injection","J1265","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.63",,,,,,,"fee schedule","1.63","2.03",
"Doripenem injection","J1267","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.02",,,,,,,"fee schedule","3.02","3.02",
"Injection, doxercalciferol","J1270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.86",,,,,,,"fee schedule","0.86","0.96",
"Injection, doxercalciferol","J1270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.86",,,,,,,"fee schedule","0.86","0.96",
"Injection, doxercalciferol","J1270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.86",,,,,,,"fee schedule","0.86","0.96",
"Injection, doxercalciferol","J1270","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.96",,,,,,,"fee schedule","0.86","0.96",
"Inj doxycycline hyclate 1 mg","J1271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.28",,,,,,,"fee schedule","0.28","0.28",
"Inj doxycycline hyclate 1 mg","J1271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.28",,,,,,,"fee schedule","0.28","0.28",
"Inj doxycycline hyclate 1 mg","J1271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.28",,,,,,,"fee schedule","0.28","0.28",
"Ecallantide injection","J1290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1523.4",,,,,,,"fee schedule","1298.67","1682.49",
"Ecallantide injection","J1290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1298.67",,,,,,,"fee schedule","1298.67","1682.49",
"Ecallantide injection","J1290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1508.31",,,,,,,"fee schedule","1298.67","1682.49",
"Ecallantide injection","J1290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1298.67",,,,,,,"fee schedule","1298.67","1682.49",
"Ecallantide injection","J1290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1298.67",,,,,,,"fee schedule","1298.67","1682.49",
"Ecallantide injection","J1290","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1682.49",,,,,,,"fee schedule","1298.67","1682.49",
"Inj, eculizumab, 2 mg","J1299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","103.06",,,,,,,"fee schedule","103.06","103.06",
"Inj, eculizumab, 2 mg","J1299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","103.06",,,,,,,"fee schedule","103.06","103.06",
"Inj, eculizumab, 2 mg","J1299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","103.06",,,,,,,"fee schedule","103.06","103.06",
"Eculizumab injection","J1300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","705.9",,,,,,,"fee schedule","705.9","781.42",
"Eculizumab injection","J1300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","712.97",,,,,,,"fee schedule","705.9","781.42",
"Eculizumab injection","J1300","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","781.42",,,,,,,"fee schedule","705.9","781.42",
"Injection, edaravone, 1 mg","J1301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","46.93",,,,,,,"fee schedule","46.93","67.34",
"Injection, edaravone, 1 mg","J1301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","46.93",,,,,,,"fee schedule","46.93","67.34",
"Injection, edaravone, 1 mg","J1301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","46.93",,,,,,,"fee schedule","46.93","67.34",
"Injection, edaravone, 1 mg","J1301","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","67.34",,,,,,,"fee schedule","46.93","67.34",
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","41.69",,,,,,,"fee schedule","41.69","41.69",
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41.69",,,,,,,"fee schedule","41.69","41.69",
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41.69",,,,,,,"fee schedule","41.69","41.69",
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","693.23",,,,,,,"fee schedule","506.73","767.17",
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","700.16",,,,,,,"fee schedule","506.73","767.17",
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","506.73",,,,,,,"fee schedule","506.73","767.17",
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","506.73",,,,,,,"fee schedule","506.73","767.17",
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","506.73",,,,,,,"fee schedule","506.73","767.17",
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","767.17",,,,,,,"fee schedule","506.73","767.17",
"Inj tofersen intrathec 1 mg","J1304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","357.28",,,,,,,"fee schedule","357.28","357.28",
"Inj tofersen intrathec 1 mg","J1304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","357.28",,,,,,,"fee schedule","357.28","357.28",
"Inj tofersen intrathec 1 mg","J1304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","357.28",,,,,,,"fee schedule","357.28","357.28",
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","428.5",,,,,,,"fee schedule","428.5","428.5",
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","428.5",,,,,,,"fee schedule","428.5","428.5",
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","428.5",,,,,,,"fee schedule","428.5","428.5",
"Injection, inclisiran, 1 mg","J1306","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","28.23",,,,,,,"fee schedule","28.23","28.23",
"Injection, inclisiran, 1 mg","J1306","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","28.23",,,,,,,"fee schedule","28.23","28.23",
"Injection, inclisiran, 1 mg","J1306","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","28.23",,,,,,,"fee schedule","28.23","28.23",
"Inj, famotidine, 0.25 mg","J1308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.02",,,,,,,"fee schedule","0.02","0.02",
"Inj, famotidine, 0.25 mg","J1308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.02",,,,,,,"fee schedule","0.02","0.02",
"Inj, famotidine, 0.25 mg","J1308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.02",,,,,,,"fee schedule","0.02","0.02",
"Elosulfase alfa, injection","J1322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","676.05",,,,,,,"fee schedule","676.05","818.5",
"Elosulfase alfa, injection","J1322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","676.05",,,,,,,"fee schedule","676.05","818.5",
"Elosulfase alfa, injection","J1322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","676.05",,,,,,,"fee schedule","676.05","818.5",
"Elosulfase alfa, injection","J1322","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","818.5",,,,,,,"fee schedule","676.05","818.5",
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","420.85",,,,,,,"fee schedule","420.85","420.85",
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","420.85",,,,,,,"fee schedule","420.85","420.85",
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","420.85",,,,,,,"fee schedule","420.85","420.85",
"Enfuvirtide injection","J1324","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.71",,,,,,,"fee schedule","2.71","2.71",
"Epoprostenol injection","J1325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","50.86",,,,,,,"fee schedule","36.97","54.85",
"Epoprostenol injection","J1325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","50.36",,,,,,,"fee schedule","36.97","54.85",
"Epoprostenol injection","J1325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36.97",,,,,,,"fee schedule","36.97","54.85",
"Epoprostenol injection","J1325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","36.97",,,,,,,"fee schedule","36.97","54.85",
"Epoprostenol injection","J1325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","36.97",,,,,,,"fee schedule","36.97","54.85",
"Epoprostenol injection","J1325","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","54.85",,,,,,,"fee schedule","36.97","54.85",
"Eptifibatide injection","J1327","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.58",,,,,,,"fee schedule","10.58","10.58",
"Ertapenem injection","J1335","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","21.12",,,,,,,"fee schedule","21.12","130.35",
"Ertapenem injection","J1335","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","21.12",,,,,,,"fee schedule","21.12","130.35",
"Ertapenem injection","J1335","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","21.12",,,,,,,"fee schedule","21.12","130.35",
"Ertapenem injection","J1335","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","130.35",,,,,,,"fee schedule","21.12","130.35",
"Erythro lactobionate /500 MG","J1364","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","151.71",,,,,,,"fee schedule","151.71","248.86",
"Erythro lactobionate /500 MG","J1364","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","151.71",,,,,,,"fee schedule","151.71","248.86",
"Erythro lactobionate /500 MG","J1364","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","151.71",,,,,,,"fee schedule","151.71","248.86",
"Erythro lactobionate /500 MG","J1364","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","248.86",,,,,,,"fee schedule","151.71","248.86",
"Estradiol valerate 10 MG inj","J1380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.79",,,,,,,"fee schedule","16.79","29.6",
"Estradiol valerate 10 MG inj","J1380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.79",,,,,,,"fee schedule","16.79","29.6",
"Estradiol valerate 10 MG inj","J1380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.79",,,,,,,"fee schedule","16.79","29.6",
"Estradiol valerate 10 MG inj","J1380","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","29.6",,,,,,,"fee schedule","16.79","29.6",
"Inj estrogen conjugate 25 MG","J1410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","880.64",,,,,,,"fee schedule","880.64","1045.51",
"Inj estrogen conjugate 25 MG","J1410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","880.64",,,,,,,"fee schedule","880.64","1045.51",
"Inj estrogen conjugate 25 MG","J1410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","880.64",,,,,,,"fee schedule","880.64","1045.51",
"Inj estrogen conjugate 25 MG","J1410","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1045.51",,,,,,,"fee schedule","880.64","1045.51",
"Inj, eteplirsen, 10 mg","J1428","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","567.68",,,,,,,"fee schedule","567.68","567.68",
"Ethanolamine oleate 100 mg","J1430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1144.71",,,,,,,"fee schedule","1144.71","1505.66",
"Ethanolamine oleate 100 mg","J1430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1144.71",,,,,,,"fee schedule","1144.71","1505.66",
"Ethanolamine oleate 100 mg","J1430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1144.71",,,,,,,"fee schedule","1144.71","1505.66",
"Ethanolamine oleate 100 mg","J1430","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1505.66",,,,,,,"fee schedule","1144.71","1505.66",
"Inj, focinvez, 1mg","J1434","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.95",,,,,,,"fee schedule","6.95","6.95",
"Inj, focinvez, 1mg","J1434","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.95",,,,,,,"fee schedule","6.95","6.95",
"Inj, focinvez, 1mg","J1434","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.95",,,,,,,"fee schedule","6.95","6.95",
"Injection estrone per 1 MG","J1435","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","1.22","1.22",
"Inj. fe derisomaltose 10 mg","J1437","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","47.9",,,,,,,"fee schedule","47.9","47.9",
"Inj. fe derisomaltose 10 mg","J1437","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","47.9",,,,,,,"fee schedule","47.9","47.9",
"Inj. fe derisomaltose 10 mg","J1437","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","47.9",,,,,,,"fee schedule","47.9","47.9",
"Etanercept injection","J1438","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2496.34",,,,,,,"fee schedule","2496.34","2496.34",
"Inj ferric carboxymaltos 1mg","J1439","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.59",,,,,,,"fee schedule","2.59","3.73",
"Inj ferric carboxymaltos 1mg","J1439","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.59",,,,,,,"fee schedule","2.59","3.73",
"Inj ferric carboxymaltos 1mg","J1439","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.59",,,,,,,"fee schedule","2.59","3.73",
"Inj ferric carboxymaltos 1mg","J1439","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.73",,,,,,,"fee schedule","2.59","3.73",
"Fecal?microbiota jslm 1 ml","J1440","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","147.05",,,,,,,"fee schedule","147.05","147.05",
"Fecal?microbiota jslm 1 ml","J1440","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","147.05",,,,,,,"fee schedule","147.05","147.05",
"Fecal?microbiota jslm 1 ml","J1440","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","147.05",,,,,,,"fee schedule","147.05","147.05",
"Inj filgrastim excl biosimil","J1442","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.26",,,,,,,"fee schedule","2.26","3.18",
"Inj filgrastim excl biosimil","J1442","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.26",,,,,,,"fee schedule","2.26","3.18",
"Inj filgrastim excl biosimil","J1442","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.26",,,,,,,"fee schedule","2.26","3.18",
"Inj filgrastim excl biosimil","J1442","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.18",,,,,,,"fee schedule","2.26","3.18",
"Inj ferric pyrophosphate cit","J1443","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.13",,,,,,,"fee schedule","0.13","0.13",
"Fe pyro cit pow 0.1 mg iron","J1444","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.13",,,,,,,"fee schedule","0.13","0.13",
"Inj tbo filgrastim 1 microg","J1447","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.77",,,,,,,"fee schedule","0.84","1.77",
"Inj tbo filgrastim 1 microg","J1447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.84",,,,,,,"fee schedule","0.84","1.77",
"Inj tbo filgrastim 1 microg","J1447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.84",,,,,,,"fee schedule","0.84","1.77",
"Inj tbo filgrastim 1 microg","J1447","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.84",,,,,,,"fee schedule","0.84","1.77",
"Injection, trilaciclib, 1mg","J1448","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12.39",,,,,,,"fee schedule","12.39","12.39",
"Injection, trilaciclib, 1mg","J1448","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12.39",,,,,,,"fee schedule","12.39","12.39",
"Injection, trilaciclib, 1mg","J1448","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12.39",,,,,,,"fee schedule","12.39","12.39",
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","52",,,,,,,"fee schedule","52","52",
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","52",,,,,,,"fee schedule","52","52",
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","52",,,,,,,"fee schedule","52","52",
"Fluconazole","J1450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.23",,,,,,,"fee schedule","8.23","43.64",
"Fluconazole","J1450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.23",,,,,,,"fee schedule","8.23","43.64",
"Fluconazole","J1450","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.23",,,,,,,"fee schedule","8.23","43.64",
"Fluconazole","J1450","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","43.64",,,,,,,"fee schedule","8.23","43.64",
"Fomepizole, 15 mg","J1451","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","29.77",,,,,,,"fee schedule","29.77","29.77",
"Fosaprepitant injection","J1453","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.27",,,,,,,"fee schedule","0.27","4.72",
"Fosaprepitant injection","J1453","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.27",,,,,,,"fee schedule","0.27","4.72",
"Fosaprepitant injection","J1453","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.72",,,,,,,"fee schedule","0.27","4.72",
"Fosaprepitant injection","J1453","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.27",,,,,,,"fee schedule","0.27","4.72",
"Inj fosnetupitant, palonoset","J1454","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1455.61",,,,,,,"fee schedule","880.65","1455.61",
"Inj fosnetupitant, palonoset","J1454","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1455.61",,,,,,,"fee schedule","880.65","1455.61",
"Inj fosnetupitant, palonoset","J1454","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1455.61",,,,,,,"fee schedule","880.65","1455.61",
"Inj fosnetupitant, palonoset","J1454","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","880.65",,,,,,,"fee schedule","880.65","1455.61",
"Foscarnet sodium injection","J1455","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","49.75",,,,,,,"fee schedule","49.75","278.92",
"Foscarnet sodium injection","J1455","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","49.75",,,,,,,"fee schedule","49.75","278.92",
"Foscarnet sodium injection","J1455","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","49.75",,,,,,,"fee schedule","49.75","278.92",
"Foscarnet sodium injection","J1455","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","278.92",,,,,,,"fee schedule","49.75","278.92",
"Inj, fosaprepitant (teva)","J1456","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.79",,,,,,,"fee schedule","2.79","2.79",
"Inj, fosaprepitant (teva)","J1456","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.79",,,,,,,"fee schedule","2.79","2.79",
"Inj, fosaprepitant (teva)","J1456","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.79",,,,,,,"fee schedule","2.79","2.79",
"Gallium nitrate injection","J1457","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.86",,,,,,,"fee schedule","4.86","4.86",
"Galsulfase injection","J1458","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1115.22",,,,,,,"fee schedule","1115.22","1348.9",
"Galsulfase injection","J1458","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1115.22",,,,,,,"fee schedule","1115.22","1348.9",
"Galsulfase injection","J1458","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1115.22",,,,,,,"fee schedule","1115.22","1348.9",
"Galsulfase injection","J1458","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1348.9",,,,,,,"fee schedule","1115.22","1348.9",
"Inj IVIG privigen 500 mg","J1459","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","131.35",,,,,,,"fee schedule","113.11","139.75",
"Inj IVIG privigen 500 mg","J1459","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","130.04",,,,,,,"fee schedule","113.11","139.75",
"Inj IVIG privigen 500 mg","J1459","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","113.11",,,,,,,"fee schedule","113.11","139.75",
"Inj IVIG privigen 500 mg","J1459","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","113.11",,,,,,,"fee schedule","113.11","139.75",
"Inj IVIG privigen 500 mg","J1459","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","113.11",,,,,,,"fee schedule","113.11","139.75",
"Inj IVIG privigen 500 mg","J1459","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","139.75",,,,,,,"fee schedule","113.11","139.75",
"Gamma globulin 1 CC inj","J1460","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","132.69",,,,,,,"fee schedule","112.44","138.85",
"Gamma globulin 1 CC inj","J1460","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","134.03",,,,,,,"fee schedule","112.44","138.85",
"Gamma globulin 1 CC inj","J1460","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","112.44",,,,,,,"fee schedule","112.44","138.85",
"Gamma globulin 1 CC inj","J1460","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","112.44",,,,,,,"fee schedule","112.44","138.85",
"Gamma globulin 1 CC inj","J1460","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","112.44",,,,,,,"fee schedule","112.44","138.85",
"Gamma globulin 1 CC inj","J1460","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","138.85",,,,,,,"fee schedule","112.44","138.85",
"Inj cutaquig 100 mg","J1551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","32.97",,,,,,,"fee schedule","32.97","32.97",
"Inj cutaquig 100 mg","J1551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","32.97",,,,,,,"fee schedule","32.97","32.97",
"Inj cutaquig 100 mg","J1551","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","32.97",,,,,,,"fee schedule","32.97","32.97",
"Inj, alyglo, 500 mg","J1552","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","317.66",,,,,,,"fee schedule","317.66","317.66",
"Inj, alyglo, 500 mg","J1552","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","317.66",,,,,,,"fee schedule","317.66","317.66",
"Inj, alyglo, 500 mg","J1552","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","317.66",,,,,,,"fee schedule","317.66","317.66",
"Inj. asceniv","J1554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1142.37",,,,,,,"fee schedule","1142.37","1142.37",
"Inj. asceniv","J1554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1142.37",,,,,,,"fee schedule","1142.37","1142.37",
"Inj. asceniv","J1554","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1142.37",,,,,,,"fee schedule","1142.37","1142.37",
"Inj cuvitru, 100 mg","J1555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","43.18",,,,,,,"fee schedule","38.37","47.09",
"Inj cuvitru, 100 mg","J1555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","38.37",,,,,,,"fee schedule","38.37","47.09",
"Inj cuvitru, 100 mg","J1555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","38.37",,,,,,,"fee schedule","38.37","47.09",
"Inj cuvitru, 100 mg","J1555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","42.74",,,,,,,"fee schedule","38.37","47.09",
"Inj cuvitru, 100 mg","J1555","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","38.37",,,,,,,"fee schedule","38.37","47.09",
"Inj cuvitru, 100 mg","J1555","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","47.09",,,,,,,"fee schedule","38.37","47.09",
"Inj, imm glob bivigam, 500mg","J1556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","177.79",,,,,,,"fee schedule","177.79","238.99",
"Inj, imm glob bivigam, 500mg","J1556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","177.79",,,,,,,"fee schedule","177.79","238.99",
"Inj, imm glob bivigam, 500mg","J1556","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","177.79",,,,,,,"fee schedule","177.79","238.99",
"Inj, imm glob bivigam, 500mg","J1556","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","238.99",,,,,,,"fee schedule","177.79","238.99",
"Gammaplex injection","J1557","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","154.19",,,,,,,"fee schedule","132.19","187.18",
"Gammaplex injection","J1557","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","132.19",,,,,,,"fee schedule","132.19","187.18",
"Gammaplex injection","J1557","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","152.67",,,,,,,"fee schedule","132.19","187.18",
"Gammaplex injection","J1557","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","132.19",,,,,,,"fee schedule","132.19","187.18",
"Gammaplex injection","J1557","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","132.19",,,,,,,"fee schedule","132.19","187.18",
"Gammaplex injection","J1557","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","187.18",,,,,,,"fee schedule","132.19","187.18",
"Inj. xembify, 100 mg","J1558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","32.85",,,,,,,"fee schedule","32.85","32.85",
"Inj. xembify, 100 mg","J1558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","32.85",,,,,,,"fee schedule","32.85","32.85",
"Inj. xembify, 100 mg","J1558","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","32.85",,,,,,,"fee schedule","32.85","32.85",
"Hizentra injection","J1559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","34.34",,,,,,,"fee schedule","31.38","35.61",
"Hizentra injection","J1559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","34.01",,,,,,,"fee schedule","31.38","35.61",
"Hizentra injection","J1559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","31.38",,,,,,,"fee schedule","31.38","35.61",
"Hizentra injection","J1559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","31.38",,,,,,,"fee schedule","31.38","35.61",
"Hizentra injection","J1559","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","31.38",,,,,,,"fee schedule","31.38","35.61",
"Hizentra injection","J1559","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","35.61",,,,,,,"fee schedule","31.38","35.61",
"Gamma globulin > 10 CC inj","J1560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1124.36",,,,,,,"fee schedule","1124.36","1388.26",
"Gamma globulin > 10 CC inj","J1560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1124.36",,,,,,,"fee schedule","1124.36","1388.26",
"Gamma globulin > 10 CC inj","J1560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1124.36",,,,,,,"fee schedule","1124.36","1388.26",
"Gamma globulin > 10 CC inj","J1560","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1388.26",,,,,,,"fee schedule","1124.36","1388.26",
"Gamunex-c/gammaked","J1561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","135.18",,,,,,,"fee schedule","111.19","138.4",
"Gamunex-c/gammaked","J1561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","111.19",,,,,,,"fee schedule","111.19","138.4",
"Gamunex-c/gammaked","J1561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","133.84",,,,,,,"fee schedule","111.19","138.4",
"Gamunex-c/gammaked","J1561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","111.19",,,,,,,"fee schedule","111.19","138.4",
"Gamunex-c/gammaked","J1561","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","111.19",,,,,,,"fee schedule","111.19","138.4",
"Gamunex-c/gammaked","J1561","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","138.4",,,,,,,"fee schedule","111.19","138.4",
"Vivaglobin, inj","J1562","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","34.27",,,,,,,"fee schedule","34.27","34.27",
"Immune globulin, powder","J1566","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","186.33",,,,,,,"fee schedule","186.33","217.29",
"Immune globulin, powder","J1566","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","205.25",,,,,,,"fee schedule","186.33","217.29",
"Immune globulin, powder","J1566","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","207.32",,,,,,,"fee schedule","186.33","217.29",
"Immune globulin, powder","J1566","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","186.33",,,,,,,"fee schedule","186.33","217.29",
"Immune globulin, powder","J1566","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","186.33",,,,,,,"fee schedule","186.33","217.29",
"Immune globulin, powder","J1566","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","217.29",,,,,,,"fee schedule","186.33","217.29",
"Octagam injection","J1568","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","128.87",,,,,,,"fee schedule","110.53","137.21",
"Octagam injection","J1568","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","127.59",,,,,,,"fee schedule","110.53","137.21",
"Octagam injection","J1568","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","110.53",,,,,,,"fee schedule","110.53","137.21",
"Octagam injection","J1568","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","110.53",,,,,,,"fee schedule","110.53","137.21",
"Octagam injection","J1568","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","110.53",,,,,,,"fee schedule","110.53","137.21",
"Octagam injection","J1568","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","137.21",,,,,,,"fee schedule","110.53","137.21",
"Gammagard liquid injection","J1569","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","133.71",,,,,,,"fee schedule","103.8","135.06",
"Gammagard liquid injection","J1569","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","103.8",,,,,,,"fee schedule","103.8","135.06",
"Gammagard liquid injection","J1569","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","135.06",,,,,,,"fee schedule","103.8","135.06",
"Gammagard liquid injection","J1569","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","103.8",,,,,,,"fee schedule","103.8","135.06",
"Gammagard liquid injection","J1569","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","103.8",,,,,,,"fee schedule","103.8","135.06",
"Gammagard liquid injection","J1569","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","134.77",,,,,,,"fee schedule","103.8","135.06",
"Ganciclovir sodium injection","J1570","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","73.8",,,,,,,"fee schedule","49.19","73.8",
"Ganciclovir sodium injection","J1570","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","73.8",,,,,,,"fee schedule","49.19","73.8",
"Ganciclovir sodium injection","J1570","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","73.8",,,,,,,"fee schedule","49.19","73.8",
"Ganciclovir sodium injection","J1570","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","49.19",,,,,,,"fee schedule","49.19","73.8",
"HepaGam B IM injection","J1571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","149.84",,,,,,,"fee schedule","149.84","198.17",
"HepaGam B IM injection","J1571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","149.84",,,,,,,"fee schedule","149.84","198.17",
"HepaGam B IM injection","J1571","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","149.84",,,,,,,"fee schedule","149.84","198.17",
"HepaGam B IM injection","J1571","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","198.17",,,,,,,"fee schedule","149.84","198.17",
"Flebogamma injection","J1572","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","114.1",,,,,,,"fee schedule","112.98","122.13",
"Flebogamma injection","J1572","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","112.98",,,,,,,"fee schedule","112.98","122.13",
"Flebogamma injection","J1572","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","122.13",,,,,,,"fee schedule","112.98","122.13",
"Hepagam B intravenous, inj","J1573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","149.84",,,,,,,"fee schedule","149.84","201.2",
"Hepagam B intravenous, inj","J1573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","149.84",,,,,,,"fee schedule","149.84","201.2",
"Hepagam B intravenous, inj","J1573","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","149.84",,,,,,,"fee schedule","149.84","201.2",
"Hepagam B intravenous, inj","J1573","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","201.2",,,,,,,"fee schedule","149.84","201.2",
"Hyqvia 100mg immuneglobulin","J1575","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","43.94",,,,,,,"fee schedule","40.4","47.93",
"Hyqvia 100mg immuneglobulin","J1575","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","44.37",,,,,,,"fee schedule","40.4","47.93",
"Hyqvia 100mg immuneglobulin","J1575","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","40.4",,,,,,,"fee schedule","40.4","47.93",
"Hyqvia 100mg immuneglobulin","J1575","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","40.4",,,,,,,"fee schedule","40.4","47.93",
"Hyqvia 100mg immuneglobulin","J1575","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","40.4",,,,,,,"fee schedule","40.4","47.93",
"Hyqvia 100mg immuneglobulin","J1575","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","47.93",,,,,,,"fee schedule","40.4","47.93",
"Inj, panzyga, 500 mg","J1576","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","161.99",,,,,,,"fee schedule","161.99","161.99",
"Inj, panzyga, 500 mg","J1576","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","161.99",,,,,,,"fee schedule","161.99","161.99",
"Inj, panzyga, 500 mg","J1576","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","161.99",,,,,,,"fee schedule","161.99","161.99",
"Garamycin gentamicin inj","J1580","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.67",,,,,,,"fee schedule","5.67","6.95",
"Garamycin gentamicin inj","J1580","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.95",,,,,,,"fee schedule","5.67","6.95",
"Garamycin gentamicin inj","J1580","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.67",,,,,,,"fee schedule","5.67","6.95",
"Garamycin gentamicin inj","J1580","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.67",,,,,,,"fee schedule","5.67","6.95",
"Injection glatiramer acetate","J1595","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","514.33",,,,,,,"fee schedule","514.33","514.33",
"Inj, glycopyrrolate, 0.1 mg","J1596","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.17",,,,,,,"fee schedule","1.17","1.17",
"Inj, glycopyrrolate, 0.1 mg","J1596","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.17",,,,,,,"fee schedule","1.17","1.17",
"Inj, glycopyrrolate, 0.1 mg","J1596","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.17",,,,,,,"fee schedule","1.17","1.17",
"Inj glycopyrrolate fres kabi","J1598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.82",,,,,,,"fee schedule","3.82","3.82",
"Inj glycopyrrolate fres kabi","J1598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.82",,,,,,,"fee schedule","3.82","3.82",
"Inj glycopyrrolate fres kabi","J1598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.82",,,,,,,"fee schedule","3.82","3.82",
"Ivig non-lyophilized, NOS","J1599","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","337.67",,,,,,,"fee schedule","337.67","337.67",
"Gold sodium thiomaleate inj","J1600","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","50.18",,,,,,,"fee schedule","50.18","50.18",
"Golimumab for iv use 1mg","J1602","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","56.1",,,,,,,"fee schedule","24.77","68.38",
"Golimumab for iv use 1mg","J1602","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","55.55",,,,,,,"fee schedule","24.77","68.38",
"Golimumab for iv use 1mg","J1602","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","24.77",,,,,,,"fee schedule","24.77","68.38",
"Golimumab for iv use 1mg","J1602","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","24.77",,,,,,,"fee schedule","24.77","68.38",
"Golimumab for iv use 1mg","J1602","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","24.77",,,,,,,"fee schedule","24.77","68.38",
"Golimumab for iv use 1mg","J1602","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","68.38",,,,,,,"fee schedule","24.77","68.38",
"Glucagon hydrochloride/1 mg","J1610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","438.75",,,,,,,"fee schedule","438.75","677.66",
"Glucagon hydrochloride/1 mg","J1610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","438.75",,,,,,,"fee schedule","438.75","677.66",
"Glucagon hydrochloride/1 mg","J1610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","438.75",,,,,,,"fee schedule","438.75","677.66",
"Glucagon hydrochloride/1 mg","J1610","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","677.66",,,,,,,"fee schedule","438.75","677.66",
"Inj glucagon hcl, fresenius","J1611","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","346.01",,,,,,,"fee schedule","346.01","346.01",
"Inj glucagon hcl, fresenius","J1611","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","346.01",,,,,,,"fee schedule","346.01","346.01",
"Inj glucagon hcl, fresenius","J1611","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","346.01",,,,,,,"fee schedule","346.01","346.01",
"Granisetron hcl injection","J1626","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.6",,,,,,,"fee schedule","0.6","0.99",
"Granisetron hcl injection","J1626","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.6",,,,,,,"fee schedule","0.6","0.99",
"Granisetron hcl injection","J1626","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.6",,,,,,,"fee schedule","0.6","0.99",
"Granisetron hcl injection","J1626","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.99",,,,,,,"fee schedule","0.6","0.99",
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12.16",,,,,,,"fee schedule","5.53","12.16",
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12.16",,,,,,,"fee schedule","5.53","12.16",
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12.16",,,,,,,"fee schedule","5.53","12.16",
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.53",,,,,,,"fee schedule","5.53","12.16",
"Inj., guselkumab, 1 mg","J1628","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","161.98",,,,,,,"fee schedule","161.98","317.9",
"Inj., guselkumab, 1 mg","J1628","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","161.98",,,,,,,"fee schedule","161.98","317.9",
"Inj., guselkumab, 1 mg","J1628","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","161.98",,,,,,,"fee schedule","161.98","317.9",
"Inj., guselkumab, 1 mg","J1628","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","317.9",,,,,,,"fee schedule","161.98","317.9",
"Haloperidol injection","J1630","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.78",,,,,,,"fee schedule","1.78","2.81",
"Haloperidol injection","J1630","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.78",,,,,,,"fee schedule","1.78","2.81",
"Haloperidol injection","J1630","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.78",,,,,,,"fee schedule","1.78","2.81",
"Haloperidol injection","J1630","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.81",,,,,,,"fee schedule","1.78","2.81",
"Haloperidol decanoate inj","J1631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.61",,,,,,,"fee schedule","10.61","52.38",
"Haloperidol decanoate inj","J1631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.61",,,,,,,"fee schedule","10.61","52.38",
"Haloperidol decanoate inj","J1631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.61",,,,,,,"fee schedule","10.61","52.38",
"Haloperidol decanoate inj","J1631","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","52.38",,,,,,,"fee schedule","10.61","52.38",
"Inj., brexanolone, 1 mg","J1632","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","260.65",,,,,,,"fee schedule","260.65","260.65",
"Hemin, 1 mg","J1640","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","76.07",,,,,,,"fee schedule","76.07","80.43",
"Hemin, 1 mg","J1640","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","76.07",,,,,,,"fee schedule","76.07","80.43",
"Hemin, 1 mg","J1640","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","76.07",,,,,,,"fee schedule","76.07","80.43",
"Hemin, 1 mg","J1640","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","80.43",,,,,,,"fee schedule","76.07","80.43",
"Inj heparin sodium per 10 u","J1642","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.04",,,,,,,"fee schedule","0.04","0.06",
"Inj heparin sodium per 10 u","J1642","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.04",,,,,,,"fee schedule","0.04","0.06",
"Inj heparin sodium per 10 u","J1642","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.04",,,,,,,"fee schedule","0.04","0.06",
"Inj heparin sodium per 10 u","J1642","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.06",,,,,,,"fee schedule","0.04","0.06",
"Inj heparin, pfizer, 1000u","J1643","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.77",,,,,,,"fee schedule","6.77","6.77",
"Inj heparin, pfizer, 1000u","J1643","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.77",,,,,,,"fee schedule","6.77","6.77",
"Inj heparin, pfizer, 1000u","J1643","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.77",,,,,,,"fee schedule","6.77","6.77",
"Inj heparin sodium per 1000u","J1644","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.5",,,,,,,"fee schedule","0.5","0.84",
"Inj heparin sodium per 1000u","J1644","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.84",,,,,,,"fee schedule","0.5","0.84",
"Inj heparin sodium per 1000u","J1644","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.5",,,,,,,"fee schedule","0.5","0.84",
"Inj heparin sodium per 1000u","J1644","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.5",,,,,,,"fee schedule","0.5","0.84",
"Dalteparin sodium","J1645","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36.9",,,,,,,"fee schedule","36.9","39.76",
"Dalteparin sodium","J1645","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","36.9",,,,,,,"fee schedule","36.9","39.76",
"Dalteparin sodium","J1645","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","36.9",,,,,,,"fee schedule","36.9","39.76",
"Dalteparin sodium","J1645","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","39.76",,,,,,,"fee schedule","36.9","39.76",
"Inj enoxaparin sodium","J1650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.19",,,,,,,"fee schedule","1.19","2.4",
"Inj enoxaparin sodium","J1650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.19",,,,,,,"fee schedule","1.19","2.4",
"Inj enoxaparin sodium","J1650","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.19",,,,,,,"fee schedule","1.19","2.4",
"Inj enoxaparin sodium","J1650","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.4",,,,,,,"fee schedule","1.19","2.4",
"Fondaparinux sodium","J1652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.97",,,,,,,"fee schedule","1.97","5.32",
"Fondaparinux sodium","J1652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.97",,,,,,,"fee schedule","1.97","5.32",
"Fondaparinux sodium","J1652","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.97",,,,,,,"fee schedule","1.97","5.32",
"Fondaparinux sodium","J1652","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.32",,,,,,,"fee schedule","1.97","5.32",
"Tinzaparin sodium injection","J1655","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13.46",,,,,,,"fee schedule","13.46","13.46",
"Tetanus immune globulin inj","J1670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1324.25",,,,,,,"fee schedule","1324.25","1812.93",
"Tetanus immune globulin inj","J1670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1324.25",,,,,,,"fee schedule","1324.25","1812.93",
"Tetanus immune globulin inj","J1670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1324.25",,,,,,,"fee schedule","1324.25","1812.93",
"Tetanus immune globulin inj","J1670","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1812.93",,,,,,,"fee schedule","1324.25","1812.93",
"Histrelin acetate","J1675","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.66",,,,,,,"fee schedule","3.66","3.66",
"Hydrocortisone sodium succ i","J1720","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","47.33",,,,,,,"fee schedule","43.74","47.33",
"Hydrocortisone sodium succ i","J1720","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","47.33",,,,,,,"fee schedule","43.74","47.33",
"Hydrocortisone sodium succ i","J1720","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","47.33",,,,,,,"fee schedule","43.74","47.33",
"Hydrocortisone sodium succ i","J1720","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","43.74",,,,,,,"fee schedule","43.74","47.33",
"Makena, 10 mg","J1726","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","62.31",,,,,,,"fee schedule","62.31","62.31",
"Inj hydroxyprogst capoat nos","J1729","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","36.65",,,,,,,"fee schedule","36.65","36.65",
"Diazoxide injection","J1730","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","371.94",,,,,,,"fee schedule","371.94","371.94",
"Ibandronate sodium injection","J1740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","51.1",,,,,,,"fee schedule","51.1","148.24",
"Ibandronate sodium injection","J1740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","51.1",,,,,,,"fee schedule","51.1","148.24",
"Ibandronate sodium injection","J1740","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","51.1",,,,,,,"fee schedule","51.1","148.24",
"Ibandronate sodium injection","J1740","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","148.24",,,,,,,"fee schedule","51.1","148.24",
"Ibuprofen injection","J1741","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.84",,,,,,,"fee schedule","6.84","9.8",
"Ibuprofen injection","J1741","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.84",,,,,,,"fee schedule","6.84","9.8",
"Ibuprofen injection","J1741","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.84",,,,,,,"fee schedule","6.84","9.8",
"Ibuprofen injection","J1741","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.8",,,,,,,"fee schedule","6.84","9.8",
"Ibutilide fumarate injection","J1742","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","820.52",,,,,,,"fee schedule","820.52","820.52",
"Idursulfase injection","J1743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1664.02",,,,,,,"fee schedule","1247.92","1840.59",
"Idursulfase injection","J1743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1680.65",,,,,,,"fee schedule","1247.92","1840.59",
"Idursulfase injection","J1743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1247.92",,,,,,,"fee schedule","1247.92","1840.59",
"Idursulfase injection","J1743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1247.92",,,,,,,"fee schedule","1247.92","1840.59",
"Idursulfase injection","J1743","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1247.92",,,,,,,"fee schedule","1247.92","1840.59",
"Idursulfase injection","J1743","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1840.59",,,,,,,"fee schedule","1247.92","1840.59",
"Icatibant injection","J1744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","288.23",,,,,,,"fee schedule","288.23","1145.4",
"Icatibant injection","J1744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","288.23",,,,,,,"fee schedule","288.23","1145.4",
"Icatibant injection","J1744","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","288.23",,,,,,,"fee schedule","288.23","1145.4",
"Icatibant injection","J1744","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1145.4",,,,,,,"fee schedule","288.23","1145.4",
"Infliximab not biosimil 10mg","J1745","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","137.63",,,,,,,"fee schedule","70.2","188.86",
"Infliximab not biosimil 10mg","J1745","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","139.02",,,,,,,"fee schedule","70.2","188.86",
"Infliximab not biosimil 10mg","J1745","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","70.2",,,,,,,"fee schedule","70.2","188.86",
"Infliximab not biosimil 10mg","J1745","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","70.2",,,,,,,"fee schedule","70.2","188.86",
"Infliximab not biosimil 10mg","J1745","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","70.2",,,,,,,"fee schedule","70.2","188.86",
"Infliximab not biosimil 10mg","J1745","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","188.86",,,,,,,"fee schedule","70.2","188.86",
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","176.99",,,,,,,"fee schedule","176.99","197.92",
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","176.99",,,,,,,"fee schedule","176.99","197.92",
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","176.99",,,,,,,"fee schedule","176.99","197.92",
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","197.92",,,,,,,"fee schedule","176.99","197.92",
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","141.28",,,,,,,"fee schedule","141.28","141.28",
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","141.28",,,,,,,"fee schedule","141.28","141.28",
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","141.28",,,,,,,"fee schedule","141.28","141.28",
"Inj iron dextran","J1750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","39.64",,,,,,,"fee schedule","39.64","48.68",
"Inj iron dextran","J1750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","39.64",,,,,,,"fee schedule","39.64","48.68",
"Inj iron dextran","J1750","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","39.64",,,,,,,"fee schedule","39.64","48.68",
"Inj iron dextran","J1750","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","48.68",,,,,,,"fee schedule","39.64","48.68",
"Iron sucrose injection","J1756","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.55",,,,,,,"fee schedule","0.55","0.72",
"Iron sucrose injection","J1756","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.55",,,,,,,"fee schedule","0.55","0.72",
"Iron sucrose injection","J1756","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.55",,,,,,,"fee schedule","0.55","0.72",
"Iron sucrose injection","J1756","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.72",,,,,,,"fee schedule","0.55","0.72",
"Imuglucerase injection","J1786","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","99.22",,,,,,,"fee schedule","99.22","144.51",
"Imuglucerase injection","J1786","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","99.22",,,,,,,"fee schedule","99.22","144.51",
"Imuglucerase injection","J1786","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","99.22",,,,,,,"fee schedule","99.22","144.51",
"Imuglucerase injection","J1786","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","144.51",,,,,,,"fee schedule","99.22","144.51",
"Droperidol injection","J1790","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18.75",,,,,,,"fee schedule","18.75","19.7",
"Droperidol injection","J1790","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19.7",,,,,,,"fee schedule","18.75","19.7",
"Droperidol injection","J1790","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19.7",,,,,,,"fee schedule","18.75","19.7",
"Droperidol injection","J1790","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19.7",,,,,,,"fee schedule","18.75","19.7",
"Propranolol injection","J1800","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11.54",,,,,,,"fee schedule","11.54","11.54",
"Inj, esmolol hcl, 10mg","J1805","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.65",,,,,,,"fee schedule","0.65","0.65",
"Inj, esmolol hcl, 10mg","J1805","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.65",,,,,,,"fee schedule","0.65","0.65",
"Inj, esmolol hcl, 10mg","J1805","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.65",,,,,,,"fee schedule","0.65","0.65",
"Inj esmolol hcl wg crit care","J1806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.94",,,,,,,"fee schedule","0.94","0.94",
"Inj esmolol hcl wg crit care","J1806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.94",,,,,,,"fee schedule","0.94","0.94",
"Inj esmolol hcl wg crit care","J1806","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.94",,,,,,,"fee schedule","0.94","0.94",
"Inj, folic acid, 0.1 mg","J1808","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.14",,,,,,,"fee schedule","0.14","0.14",
"Inj, folic acid, 0.1 mg","J1808","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.14",,,,,,,"fee schedule","0.14","0.14",
"Inj, folic acid, 0.1 mg","J1808","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.14",,,,,,,"fee schedule","0.14","0.14",
"Fiasp for insulin pump use","J1811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15.34",,,,,,,"fee schedule","15.34","15.34",
"Fiasp for insulin pump use","J1811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15.34",,,,,,,"fee schedule","15.34","15.34",
"Fiasp for insulin pump use","J1811","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15.34",,,,,,,"fee schedule","15.34","15.34",
"Lyumjev for insulin pump use","J1813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","35.25",,,,,,,"fee schedule","35.25","35.25",
"Lyumjev for insulin pump use","J1813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","35.25",,,,,,,"fee schedule","35.25","35.25",
"Lyumjev for insulin pump use","J1813","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","35.25",,,,,,,"fee schedule","35.25","35.25",
"Insulin injection","J1815","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.02",,,,,,,"fee schedule","3.02","3.02",
"Insulin for insulin pump use","J1817","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.73",,,,,,,"fee schedule","5.73","36.14",
"Insulin for insulin pump use","J1817","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.73",,,,,,,"fee schedule","5.73","36.14",
"Insulin for insulin pump use","J1817","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.73",,,,,,,"fee schedule","5.73","36.14",
"Insulin for insulin pump use","J1817","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","36.14",,,,,,,"fee schedule","5.73","36.14",
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1114.13",,,,,,,"fee schedule","1114.13","1114.13",
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1114.13",,,,,,,"fee schedule","1114.13","1114.13",
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1114.13",,,,,,,"fee schedule","1114.13","1114.13",
"Interferon Beta-1A inj","J1826","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7718.55",,,,,,,"fee schedule","7718.55","7718.55",
"Interferon beta-1b / .25 MG","J1830","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1258.86",,,,,,,"fee schedule","1258.86","1258.86",
"Injection, isavuconazonium","J1833","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.71",,,,,,,"fee schedule","2.71","2.71",
"Itraconazole injection","J1835","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3440.69",,,,,,,"fee schedule","3440.69","3440.69",
"Inj, metronidazole, 10 mg","J1836","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.06",,,,,,,"fee schedule","0.06","0.06",
"Inj, metronidazole, 10 mg","J1836","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.06",,,,,,,"fee schedule","0.06","0.06",
"Inj, metronidazole, 10 mg","J1836","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.06",,,,,,,"fee schedule","0.06","0.06",
"Ketorolac tromethamine inj","J1885","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.15",,,,,,,"fee schedule","1.15","1.87",
"Ketorolac tromethamine inj","J1885","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.15",,,,,,,"fee schedule","1.15","1.87",
"Ketorolac tromethamine inj","J1885","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.15",,,,,,,"fee schedule","1.15","1.87",
"Ketorolac tromethamine inj","J1885","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.87",,,,,,,"fee schedule","1.15","1.87",
"Inj, labetalol hcl, 5mg","J1920","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.96",,,,,,,"fee schedule","0.96","0.96",
"Inj, labetalol hcl, 5mg","J1920","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.96",,,,,,,"fee schedule","0.96","0.96",
"Inj, labetalol hcl, 5mg","J1920","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.96",,,,,,,"fee schedule","0.96","0.96",
"Inj labetalol hcl hikma, 5mg","J1921","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.18",,,,,,,"fee schedule","3.18","3.18",
"Inj labetalol hcl hikma, 5mg","J1921","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.18",,,,,,,"fee schedule","3.18","3.18",
"Inj labetalol hcl hikma, 5mg","J1921","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.18",,,,,,,"fee schedule","3.18","3.18",
"Lanreotide injection","J1930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","90.97",,,,,,,"fee schedule","90.97","223.24",
"Lanreotide injection","J1930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","90.97",,,,,,,"fee schedule","90.97","223.24",
"Lanreotide injection","J1930","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","90.97",,,,,,,"fee schedule","90.97","223.24",
"Lanreotide injection","J1930","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","223.24",,,,,,,"fee schedule","90.97","223.24",
"Laronidase injection","J1931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","88.79",,,,,,,"fee schedule","88.79","109.01",
"Laronidase injection","J1931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","88.79",,,,,,,"fee schedule","88.79","109.01",
"Laronidase injection","J1931","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","88.79",,,,,,,"fee schedule","88.79","109.01",
"Laronidase injection","J1931","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","109.01",,,,,,,"fee schedule","88.79","109.01",
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","58.47",,,,,,,"fee schedule","58.47","58.47",
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","58.47",,,,,,,"fee schedule","58.47","58.47",
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","58.47",,,,,,,"fee schedule","58.47","58.47",
"Inj, furosemide, 1 mg","J1938","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.05",,,,,,,"fee schedule","0.05","0.05",
"Inj, furosemide, 1 mg","J1938","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.05",,,,,,,"fee schedule","0.05","0.05",
"Inj, furosemide, 1 mg","J1938","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.05",,,,,,,"fee schedule","0.05","0.05",
"Inj, bumetanide, 0.5 mg","J1939","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.31",,,,,,,"fee schedule","1.31","1.31",
"Inj, bumetanide, 0.5 mg","J1939","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.31",,,,,,,"fee schedule","1.31","1.31",
"Inj, bumetanide, 0.5 mg","J1939","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.31",,,,,,,"fee schedule","1.31","1.31",
"Furosemide injection","J1940","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.15",,,,,,,"fee schedule","2.15","2.15",
"Inj., aristada initio, 1 mg","J1943","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.23",,,,,,,"fee schedule","7.23","9.42",
"Inj., aristada initio, 1 mg","J1943","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.23",,,,,,,"fee schedule","7.23","9.42",
"Inj., aristada initio, 1 mg","J1943","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.23",,,,,,,"fee schedule","7.23","9.42",
"Inj., aristada initio, 1 mg","J1943","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.42",,,,,,,"fee schedule","7.23","9.42",
"Aripirazole lauroxil 1 mg","J1944","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.5",,,,,,,"fee schedule","7.5","9.18",
"Aripirazole lauroxil 1 mg","J1944","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.5",,,,,,,"fee schedule","7.5","9.18",
"Aripirazole lauroxil 1 mg","J1944","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.5",,,,,,,"fee schedule","7.5","9.18",
"Aripirazole lauroxil 1 mg","J1944","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.18",,,,,,,"fee schedule","7.5","9.18",
"Lepirudin","J1945","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","549.37",,,,,,,"fee schedule","549.37","549.37",
"Leuprolide acetate /3.75 mg","J1950","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4849.15",,,,,,,"fee schedule","3841.68","4897.64",
"Leuprolide acetate /3.75 mg","J1950","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3841.68",,,,,,,"fee schedule","3841.68","4897.64",
"Leuprolide acetate /3.75 mg","J1950","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4897.64",,,,,,,"fee schedule","3841.68","4897.64",
"Leuprolide acetate /3.75 mg","J1950","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3841.68",,,,,,,"fee schedule","3841.68","4897.64",
"Leuprolide acetate /3.75 mg","J1950","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3841.68",,,,,,,"fee schedule","3841.68","4897.64",
"Leuprolide acetate /3.75 mg","J1950","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4404.89",,,,,,,"fee schedule","3841.68","4897.64",
"Inj fensolvi 0.25 mg","J1951","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","308.79",,,,,,,"fee schedule","308.79","308.79",
"Inj fensolvi 0.25 mg","J1951","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","308.79",,,,,,,"fee schedule","308.79","308.79",
"Inj fensolvi 0.25 mg","J1951","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","308.79",,,,,,,"fee schedule","308.79","308.79",
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","120.47",,,,,,,"fee schedule","120.47","120.47",
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","120.47",,,,,,,"fee schedule","120.47","120.47",
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","120.47",,,,,,,"fee schedule","120.47","120.47",
"Levetiracetam injection","J1953","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.12",,,,,,,"fee schedule","0.12","0.35",
"Levetiracetam injection","J1953","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.12",,,,,,,"fee schedule","0.12","0.35",
"Levetiracetam injection","J1953","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.12",,,,,,,"fee schedule","0.12","0.35",
"Levetiracetam injection","J1953","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.35",,,,,,,"fee schedule","0.12","0.35",
"Leuprolide depot cipla 7.5mg","J1954","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","507.71",,,,,,,"fee schedule","507.71","507.71",
"Leuprolide depot cipla 7.5mg","J1954","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","507.71",,,,,,,"fee schedule","507.71","507.71",
"Leuprolide depot cipla 7.5mg","J1954","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","507.71",,,,,,,"fee schedule","507.71","507.71",
"Inj levocarnitine per 1 gm","J1955","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","56.06",,,,,,,"fee schedule","56.06","69.34",
"Inj levocarnitine per 1 gm","J1955","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","56.06",,,,,,,"fee schedule","56.06","69.34",
"Inj levocarnitine per 1 gm","J1955","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","56.06",,,,,,,"fee schedule","56.06","69.34",
"Inj levocarnitine per 1 gm","J1955","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","69.34",,,,,,,"fee schedule","56.06","69.34",
"Levofloxacin injection","J1956","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.36",,,,,,,"fee schedule","1.47","2.36",
"Levofloxacin injection","J1956","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.36",,,,,,,"fee schedule","1.47","2.36",
"Levofloxacin injection","J1956","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.36",,,,,,,"fee schedule","1.47","2.36",
"Levofloxacin injection","J1956","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.47",,,,,,,"fee schedule","1.47","2.36",
"Levorphanol tartrate inj","J1960","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11.01",,,,,,,"fee schedule","11.01","11.01",
"Inj, lenacapavir, 1 mg","J1961","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","50.67",,,,,,,"fee schedule","50.67","50.67",
"Inj, lenacapavir, 1 mg","J1961","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","50.67",,,,,,,"fee schedule","50.67","50.67",
"Inj, lenacapavir, 1 mg","J1961","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","50.67",,,,,,,"fee schedule","50.67","50.67",
"Hyoscyamine sulfate inj","J1980","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","107.13",,,,,,,"fee schedule","107.13","107.13",
"Chlordiazepoxide injection","J1990","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","75.87",,,,,,,"fee schedule","75.87","75.87",
"Inj, lidocaine in d5w, 1 mg","J2002","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.01",,,,,,,"fee schedule","0.01","0.01",
"Inj, lidocaine in d5w, 1 mg","J2002","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.01",,,,,,,"fee schedule","0.01","0.01",
"Inj, lidocaine in d5w, 1 mg","J2002","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.01",,,,,,,"fee schedule","0.01","0.01",
"Lincomycin injection","J2010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14.35",,,,,,,"fee schedule","14.35","41.46",
"Lincomycin injection","J2010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14.35",,,,,,,"fee schedule","14.35","41.46",
"Lincomycin injection","J2010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14.35",,,,,,,"fee schedule","14.35","41.46",
"Lincomycin injection","J2010","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","41.46",,,,,,,"fee schedule","14.35","41.46",
"Linezolid injection","J2020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.99",,,,,,,"fee schedule","7.99","21.12",
"Linezolid injection","J2020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.99",,,,,,,"fee schedule","7.99","21.12",
"Linezolid injection","J2020","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.99",,,,,,,"fee schedule","7.99","21.12",
"Linezolid injection","J2020","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21.12",,,,,,,"fee schedule","7.99","21.12",
"Inj, linezolid (hospira)","J2021","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14.58",,,,,,,"fee schedule","14.58","14.58",
"Inj, linezolid (hospira)","J2021","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14.58",,,,,,,"fee schedule","14.58","14.58",
"Inj, linezolid (hospira)","J2021","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14.58",,,,,,,"fee schedule","14.58","14.58",
"Lorazepam injection","J2060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.6",,,,,,,"fee schedule","2.55","3.6",
"Lorazepam injection","J2060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.6",,,,,,,"fee schedule","2.55","3.6",
"Lorazepam injection","J2060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.6",,,,,,,"fee schedule","2.55","3.6",
"Lorazepam injection","J2060","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.55",,,,,,,"fee schedule","2.55","3.6",
"Loxapine for inhalation 1 mg","J2062","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","61.03",,,,,,,"fee schedule","61.03","61.03",
"Mannitol injection","J2150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.2",,,,,,,"fee schedule","5.2","7.16",
"Mannitol injection","J2150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.2",,,,,,,"fee schedule","5.2","7.16",
"Mannitol injection","J2150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.2",,,,,,,"fee schedule","5.2","7.16",
"Mannitol injection","J2150","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.16",,,,,,,"fee schedule","5.2","7.16",
"Mecasermin injection","J2170","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","498.98",,,,,,,"fee schedule","498.98","498.98",
"Meperidine hydrochl /100 MG","J2175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","23.31",,,,,,,"fee schedule","16.96","23.31",
"Meperidine hydrochl /100 MG","J2175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","23.31",,,,,,,"fee schedule","16.96","23.31",
"Meperidine hydrochl /100 MG","J2175","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16.96",,,,,,,"fee schedule","16.96","23.31",
"Meperidine hydrochl /100 MG","J2175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","23.31",,,,,,,"fee schedule","16.96","23.31",
"Meperidine/promethazine inj","J2180","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","28.14",,,,,,,"fee schedule","28.14","28.14",
"Injection, mepolizumab, 1mg","J2182","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","89.32",,,,,,,"fee schedule","70.24","97.51",
"Injection, mepolizumab, 1mg","J2182","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","88.43",,,,,,,"fee schedule","70.24","97.51",
"Injection, mepolizumab, 1mg","J2182","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","70.24",,,,,,,"fee schedule","70.24","97.51",
"Injection, mepolizumab, 1mg","J2182","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","70.24",,,,,,,"fee schedule","70.24","97.51",
"Injection, mepolizumab, 1mg","J2182","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","70.24",,,,,,,"fee schedule","70.24","97.51",
"Injection, mepolizumab, 1mg","J2182","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","97.51",,,,,,,"fee schedule","70.24","97.51",
"Inj meropenem (wg crit care)","J2183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.69",,,,,,,"fee schedule","3.69","3.69",
"Inj meropenem (wg crit care)","J2183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.69",,,,,,,"fee schedule","3.69","3.69",
"Inj meropenem (wg crit care)","J2183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.69",,,,,,,"fee schedule","3.69","3.69",
"Inj, meropenem (b. braun)","J2184","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.8",,,,,,,"fee schedule","4.8","4.8",
"Inj, meropenem (b. braun)","J2184","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.8",,,,,,,"fee schedule","4.8","4.8",
"Inj, meropenem (b. braun)","J2184","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.8",,,,,,,"fee schedule","4.8","4.8",
"Meropenem","J2185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.99",,,,,,,"fee schedule","0.99","2.75",
"Meropenem","J2185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.99",,,,,,,"fee schedule","0.99","2.75",
"Meropenem","J2185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.99",,,,,,,"fee schedule","0.99","2.75",
"Meropenem","J2185","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.75",,,,,,,"fee schedule","0.99","2.75",
"Inj., meropenem, vaborbactam","J2186","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.06",,,,,,,"fee schedule","6.06","6.06",
"Methylergonovin maleate inj","J2210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","48.96",,,,,,,"fee schedule","48.96","60.79",
"Methylergonovin maleate inj","J2210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","48.96",,,,,,,"fee schedule","48.96","60.79",
"Methylergonovin maleate inj","J2210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","48.96",,,,,,,"fee schedule","48.96","60.79",
"Methylergonovin maleate inj","J2210","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","60.79",,,,,,,"fee schedule","48.96","60.79",
"Methylnaltrexone injection","J2212","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.76",,,,,,,"fee schedule","4.76","4.76",
"Inj, micafungin (baxter)","J2246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.47",,,,,,,"fee schedule","1.47","1.47",
"Inj, micafungin (baxter)","J2246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.47",,,,,,,"fee schedule","1.47","1.47",
"Inj, micafungin (baxter)","J2246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.47",,,,,,,"fee schedule","1.47","1.47",
"Inj, micafungin (par pharm)","J2247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.7",,,,,,,"fee schedule","0.7","0.7",
"Inj, micafungin (par pharm)","J2247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.7",,,,,,,"fee schedule","0.7","0.7",
"Inj, micafungin (par pharm)","J2247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.7",,,,,,,"fee schedule","0.7","0.7",
"Micafungin sodium injection","J2248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.65",,,,,,,"fee schedule","0.65","3.66",
"Micafungin sodium injection","J2248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.65",,,,,,,"fee schedule","0.65","3.66",
"Micafungin sodium injection","J2248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.65",,,,,,,"fee schedule","0.65","3.66",
"Micafungin sodium injection","J2248","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.66",,,,,,,"fee schedule","0.65","3.66",
"Inj midazolam hydrochloride","J2250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.3",,,,,,,"fee schedule","0.3","0.37",
"Inj midazolam hydrochloride","J2250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.3",,,,,,,"fee schedule","0.3","0.37",
"Inj midazolam hydrochloride","J2250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.3",,,,,,,"fee schedule","0.3","0.37",
"Inj midazolam hydrochloride","J2250","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.37",,,,,,,"fee schedule","0.3","0.37",
"Inj midazolam (wg crit care)","J2251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.39",,,,,,,"fee schedule","0.39","0.39",
"Inj midazolam (wg crit care)","J2251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.39",,,,,,,"fee schedule","0.39","0.39",
"Inj midazolam (wg crit care)","J2251","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.39",,,,,,,"fee schedule","0.39","0.39",
"Inj milrinone lactate / 5 mg","J2260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.61",,,,,,,"fee schedule","3.61","5.63",
"Inj milrinone lactate / 5 mg","J2260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.61",,,,,,,"fee schedule","3.61","5.63",
"Inj milrinone lactate / 5 mg","J2260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.61",,,,,,,"fee schedule","3.61","5.63",
"Inj milrinone lactate / 5 mg","J2260","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.63",,,,,,,"fee schedule","3.61","5.63",
"Minocycline hydrochloride","J2265","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.7",,,,,,,"fee schedule","6.7","6.7",
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","109.4",,,,,,,"fee schedule","109.4","109.4",
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","109.4",,,,,,,"fee schedule","109.4","109.4",
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","109.4",,,,,,,"fee schedule","109.4","109.4",
"Morphine sulfate injection","J2270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.65",,,,,,,"fee schedule","10.65","12.65",
"Morphine sulfate injection","J2270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.65",,,,,,,"fee schedule","10.65","12.65",
"Morphine sulfate injection","J2270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.65",,,,,,,"fee schedule","10.65","12.65",
"Morphine sulfate injection","J2270","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.65",,,,,,,"fee schedule","10.65","12.65",
"Inj, morphine (fresenius)","J2272","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15.27",,,,,,,"fee schedule","15.27","15.27",
"Inj, morphine (fresenius)","J2272","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15.27",,,,,,,"fee schedule","15.27","15.27",
"Inj, morphine (fresenius)","J2272","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15.27",,,,,,,"fee schedule","15.27","15.27",
"In morphine preservativ free","J2274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","22.59",,,,,,,"fee schedule","22.59","39.34",
"In morphine preservativ free","J2274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","22.59",,,,,,,"fee schedule","22.59","39.34",
"In morphine preservativ free","J2274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","22.59",,,,,,,"fee schedule","22.59","39.34",
"In morphine preservativ free","J2274","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","39.34",,,,,,,"fee schedule","22.59","39.34",
"Inj, motixafortide, 0.25 mg","J2277","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","58",,,,,,,"fee schedule","58","58",
"Inj, motixafortide, 0.25 mg","J2277","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","58",,,,,,,"fee schedule","58","58",
"Inj, motixafortide, 0.25 mg","J2277","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","58",,,,,,,"fee schedule","58","58",
"Ziconotide injection","J2278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","22.31",,,,,,,"fee schedule","22.31","27.93",
"Ziconotide injection","J2278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","22.31",,,,,,,"fee schedule","22.31","27.93",
"Ziconotide injection","J2278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","22.31",,,,,,,"fee schedule","22.31","27.93",
"Ziconotide injection","J2278","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","27.93",,,,,,,"fee schedule","22.31","27.93",
"Inj, moxifloxacin 100 mg","J2280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19.72",,,,,,,"fee schedule","19.72","29.95",
"Inj, moxifloxacin 100 mg","J2280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19.72",,,,,,,"fee schedule","19.72","29.95",
"Inj, moxifloxacin 100 mg","J2280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19.72",,,,,,,"fee schedule","19.72","29.95",
"Inj, moxifloxacin 100 mg","J2280","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","29.95",,,,,,,"fee schedule","19.72","29.95",
"Inj moxifloxacin (fres kabi)","J2281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.34",,,,,,,"fee schedule","16.34","16.34",
"Inj moxifloxacin (fres kabi)","J2281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.34",,,,,,,"fee schedule","16.34","16.34",
"Inj moxifloxacin (fres kabi)","J2281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.34",,,,,,,"fee schedule","16.34","16.34",
"Inj nalbuphine hydrochloride","J2300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.08",,,,,,,"fee schedule","7.08","8.8",
"Inj nalbuphine hydrochloride","J2300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.08",,,,,,,"fee schedule","7.08","8.8",
"Inj nalbuphine hydrochloride","J2300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.08",,,,,,,"fee schedule","7.08","8.8",
"Inj nalbuphine hydrochloride","J2300","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.8",,,,,,,"fee schedule","7.08","8.8",
"Inj, nitroglycerin, 5 mg","J2305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.08",,,,,,,"fee schedule","3.08","3.08",
"Inj, nitroglycerin, 5 mg","J2305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.08",,,,,,,"fee schedule","3.08","3.08",
"Inj, nitroglycerin, 5 mg","J2305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.08",,,,,,,"fee schedule","3.08","3.08",
"Inj naloxone hydrochloride","J2310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","21.19",,,,,,,"fee schedule","21.19","41.91",
"Inj naloxone hydrochloride","J2310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","21.19",,,,,,,"fee schedule","21.19","41.91",
"Inj naloxone hydrochloride","J2310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","21.19",,,,,,,"fee schedule","21.19","41.91",
"Inj naloxone hydrochloride","J2310","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","41.91",,,,,,,"fee schedule","21.19","41.91",
"Inj, naloxone hcl (zimhi)","J2311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.44",,,,,,,"fee schedule","3.44","3.44",
"Inj, naloxone hcl (zimhi)","J2311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.44",,,,,,,"fee schedule","3.44","3.44",
"Inj, naloxone hcl (zimhi)","J2311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.44",,,,,,,"fee schedule","3.44","3.44",
"Naltrexone, depot form","J2315","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.48",,,,,,,"fee schedule","9.48","10.94",
"Naltrexone, depot form","J2315","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.48",,,,,,,"fee schedule","9.48","10.94",
"Naltrexone, depot form","J2315","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.48",,,,,,,"fee schedule","9.48","10.94",
"Naltrexone, depot form","J2315","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.94",,,,,,,"fee schedule","9.48","10.94",
"Nandrolone decanoate 50 MG","J2320","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14.68",,,,,,,"fee schedule","14.68","14.68",
"Natalizumab injection","J2323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","69.3",,,,,,,"fee schedule","56.05","70.79",
"Natalizumab injection","J2323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","68.61",,,,,,,"fee schedule","56.05","70.79",
"Natalizumab injection","J2323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","56.05",,,,,,,"fee schedule","56.05","70.79",
"Natalizumab injection","J2323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","56.05",,,,,,,"fee schedule","56.05","70.79",
"Natalizumab injection","J2323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","56.05",,,,,,,"fee schedule","56.05","70.79",
"Natalizumab injection","J2323","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","70.79",,,,,,,"fee schedule","56.05","70.79",
"Nesiritide injection","J2325","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","253.61",,,,,,,"fee schedule","253.61","253.61",
"Inj, nusinersen, 0.1mg","J2326","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3772.5",,,,,,,"fee schedule","3772.5","3772.5",
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","34.18",,,,,,,"fee schedule","31.07","34.18",
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","34.18",,,,,,,"fee schedule","31.07","34.18",
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","34.18",,,,,,,"fee schedule","31.07","34.18",
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","31.07",,,,,,,"fee schedule","31.07","34.18",
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","157.91",,,,,,,"fee schedule","137.81","157.91",
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","157.91",,,,,,,"fee schedule","137.81","157.91",
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","157.91",,,,,,,"fee schedule","137.81","157.91",
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","137.81",,,,,,,"fee schedule","137.81","157.91",
"Injection, ocrelizumab, 1 mg","J2350","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","175.71",,,,,,,"fee schedule","132.96","194.68",
"Injection, ocrelizumab, 1 mg","J2350","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","177.46",,,,,,,"fee schedule","132.96","194.68",
"Injection, ocrelizumab, 1 mg","J2350","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","132.96",,,,,,,"fee schedule","132.96","194.68",
"Injection, ocrelizumab, 1 mg","J2350","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","132.96",,,,,,,"fee schedule","132.96","194.68",
"Injection, ocrelizumab, 1 mg","J2350","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","132.96",,,,,,,"fee schedule","132.96","194.68",
"Injection, ocrelizumab, 1 mg","J2350","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","194.68",,,,,,,"fee schedule","132.96","194.68",
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","103.93",,,,,,,"fee schedule","103.93","103.93",
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","103.93",,,,,,,"fee schedule","103.93","103.93",
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","103.93",,,,,,,"fee schedule","103.93","103.93",
"Octreotide injection, depot","J2353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","636.65",,,,,,,"fee schedule","470.56","698.69",
"Octreotide injection, depot","J2353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","470.56",,,,,,,"fee schedule","470.56","698.69",
"Octreotide injection, depot","J2353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","470.56",,,,,,,"fee schedule","470.56","698.69",
"Octreotide injection, depot","J2353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","630.34",,,,,,,"fee schedule","470.56","698.69",
"Octreotide injection, depot","J2353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","470.56",,,,,,,"fee schedule","470.56","698.69",
"Octreotide injection, depot","J2353","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","698.69",,,,,,,"fee schedule","470.56","698.69",
"Octreotide inj, non-depot","J2354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.36",,,,,,,"fee schedule","1.36","2.89",
"Octreotide inj, non-depot","J2354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.36",,,,,,,"fee schedule","1.36","2.89",
"Octreotide inj, non-depot","J2354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.36",,,,,,,"fee schedule","1.36","2.89",
"Octreotide inj, non-depot","J2354","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.89",,,,,,,"fee schedule","1.36","2.89",
"Oprelvekin injection","J2355","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.53",,,,,,,"fee schedule","4.53","4.53",
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","40.86",,,,,,,"fee schedule","40.86","40.86",
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","40.86",,,,,,,"fee schedule","40.86","40.86",
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","40.86",,,,,,,"fee schedule","40.86","40.86",
"Omalizumab injection","J2357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","115.82",,,,,,,"fee schedule","92.27","125.95",
"Omalizumab injection","J2357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","92.27",,,,,,,"fee schedule","92.27","125.95",
"Omalizumab injection","J2357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","114.68",,,,,,,"fee schedule","92.27","125.95",
"Omalizumab injection","J2357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","92.27",,,,,,,"fee schedule","92.27","125.95",
"Omalizumab injection","J2357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","92.27",,,,,,,"fee schedule","92.27","125.95",
"Omalizumab injection","J2357","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","125.95",,,,,,,"fee schedule","92.27","125.95",
"Olanzapine long-acting inj","J2358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.71",,,,,,,"fee schedule","6.71","9.9",
"Olanzapine long-acting inj","J2358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.71",,,,,,,"fee schedule","6.71","9.9",
"Olanzapine long-acting inj","J2358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.71",,,,,,,"fee schedule","6.71","9.9",
"Olanzapine long-acting inj","J2358","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.9",,,,,,,"fee schedule","6.71","9.9",
"Inj. olanzapine, 0.5mg","J2359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.13",,,,,,,"fee schedule","2.13","2.13",
"Inj. olanzapine, 0.5mg","J2359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.13",,,,,,,"fee schedule","2.13","2.13",
"Inj. olanzapine, 0.5mg","J2359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.13",,,,,,,"fee schedule","2.13","2.13",
"Orphenadrine injection","J2360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","28.35",,,,,,,"fee schedule","26.14","28.35",
"Orphenadrine injection","J2360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","28.35",,,,,,,"fee schedule","26.14","28.35",
"Orphenadrine injection","J2360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","28.35",,,,,,,"fee schedule","26.14","28.35",
"Orphenadrine injection","J2360","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","26.14",,,,,,,"fee schedule","26.14","28.35",
"Inj, biorphen, 20 micrograms","J2372","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.4",,,,,,,"fee schedule","0.4","0.4",
"Inj, biorphen, 20 micrograms","J2372","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.4",,,,,,,"fee schedule","0.4","0.4",
"Inj, biorphen, 20 micrograms","J2372","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.4",,,,,,,"fee schedule","0.4","0.4",
"Inj, immphentiv, 20 mcg","J2373","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.32",,,,,,,"fee schedule","0.32","0.32",
"Inj, immphentiv, 20 mcg","J2373","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.32",,,,,,,"fee schedule","0.32","0.32",
"Inj, immphentiv, 20 mcg","J2373","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.32",,,,,,,"fee schedule","0.32","0.32",
"Chloroprocaine hcl injection","J2400","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","89.51",,,,,,,"fee schedule","89.51","89.51",
"Chloroprocaine hcl injection","J2401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.09",,,,,,,"fee schedule","0.09","0.09",
"Chloroprocaine hcl injection","J2401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.09",,,,,,,"fee schedule","0.09","0.09",
"Chloroprocaine hcl injection","J2401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.09",,,,,,,"fee schedule","0.09","0.09",
"Chloroprocaine opht gel, 1mg","J2403","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.39",,,,,,,"fee schedule","1.39","1.39",
"Chloroprocaine opht gel, 1mg","J2403","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.39",,,,,,,"fee schedule","1.39","1.39",
"Chloroprocaine opht gel, 1mg","J2403","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.39",,,,,,,"fee schedule","1.39","1.39",
"Inj, nicardipine 0.1 mg","J2404","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.2",,,,,,,"fee schedule","0.2","0.2",
"Inj, nicardipine 0.1 mg","J2404","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.2",,,,,,,"fee schedule","0.2","0.2",
"Inj, nicardipine 0.1 mg","J2404","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.2",,,,,,,"fee schedule","0.2","0.2",
"Ondansetron hcl injection","J2405","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.32",,,,,,,"fee schedule","0.2","0.32",
"Ondansetron hcl injection","J2405","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.2",,,,,,,"fee schedule","0.2","0.32",
"Ondansetron hcl injection","J2405","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.2",,,,,,,"fee schedule","0.2","0.32",
"Ondansetron hcl injection","J2405","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.2",,,,,,,"fee schedule","0.2","0.32",
"Injection, oritavancin 10 mg","J2406","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","98.36",,,,,,,"fee schedule","98.36","98.36",
"Injection, oritavancin 10 mg","J2406","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","98.36",,,,,,,"fee schedule","98.36","98.36",
"Injection, oritavancin 10 mg","J2406","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","98.36",,,,,,,"fee schedule","98.36","98.36",
"Injection, oritavancin","J2407","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","65.61",,,,,,,"fee schedule","65.61","78.91",
"Injection, oritavancin","J2407","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","65.61",,,,,,,"fee schedule","65.61","78.91",
"Injection, oritavancin","J2407","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","65.61",,,,,,,"fee schedule","65.61","78.91",
"Injection, oritavancin","J2407","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","78.91",,,,,,,"fee schedule","65.61","78.91",
"Oxymorphone hcl injection","J2410","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.58",,,,,,,"fee schedule","8.58","8.58",
"Palifermin injection","J2425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","78.18",,,,,,,"fee schedule","71.98","78.18",
"Palifermin injection","J2425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","78.18",,,,,,,"fee schedule","71.98","78.18",
"Palifermin injection","J2425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","78.18",,,,,,,"fee schedule","71.98","78.18",
"Palifermin injection","J2425","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","71.98",,,,,,,"fee schedule","71.98","78.18",
"Paliperidone palmitate inj","J2426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","33.9",,,,,,,"fee schedule","33.9","39.4",
"Paliperidone palmitate inj","J2426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","33.9",,,,,,,"fee schedule","33.9","39.4",
"Paliperidone palmitate inj","J2426","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","33.9",,,,,,,"fee schedule","33.9","39.4",
"Paliperidone palmitate inj","J2426","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","39.4",,,,,,,"fee schedule","33.9","39.4",
"Inj, invega hafyera/trinza","J2427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","29.15",,,,,,,"fee schedule","29.15","29.15",
"Inj, invega hafyera/trinza","J2427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","29.15",,,,,,,"fee schedule","29.15","29.15",
"Inj, invega hafyera/trinza","J2427","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","29.15",,,,,,,"fee schedule","29.15","29.15",
"Pamidronate disodium /30 mg","J2430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","31.91",,,,,,,"fee schedule","31.91","35.05",
"Pamidronate disodium /30 mg","J2430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","31.91",,,,,,,"fee schedule","31.91","35.05",
"Pamidronate disodium /30 mg","J2430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","31.91",,,,,,,"fee schedule","31.91","35.05",
"Pamidronate disodium /30 mg","J2430","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","35.05",,,,,,,"fee schedule","31.91","35.05",
"Papaverin hcl injection","J2440","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","153.42",,,,,,,"fee schedule","153.42","153.42",
"Inj, palonosetron (avyxa)","J2468","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","137.78",,,,,,,"fee schedule","137.78","137.78",
"Inj, palonosetron (avyxa)","J2468","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","137.78",,,,,,,"fee schedule","137.78","137.78",
"Inj, palonosetron (avyxa)","J2468","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","137.78",,,,,,,"fee schedule","137.78","137.78",
"Palonosetron hcl","J2469","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.15",,,,,,,"fee schedule","1.15","11.49",
"Palonosetron hcl","J2469","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.15",,,,,,,"fee schedule","1.15","11.49",
"Palonosetron hcl","J2469","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.15",,,,,,,"fee schedule","1.15","11.49",
"Palonosetron hcl","J2469","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11.49",,,,,,,"fee schedule","1.15","11.49",
"Paricalcitol","J2501","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.86",,,,,,,"fee schedule","1.86","2.81",
"Paricalcitol","J2501","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.86",,,,,,,"fee schedule","1.86","2.81",
"Paricalcitol","J2501","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.86",,,,,,,"fee schedule","1.86","2.81",
"Paricalcitol","J2501","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.81",,,,,,,"fee schedule","1.86","2.81",
"Inj, pasireotide long acting","J2502","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1211.97",,,,,,,"fee schedule","1095.34","1211.97",
"Inj, pasireotide long acting","J2502","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1211.97",,,,,,,"fee schedule","1095.34","1211.97",
"Inj, pasireotide long acting","J2502","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1211.97",,,,,,,"fee schedule","1095.34","1211.97",
"Inj, pasireotide long acting","J2502","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1095.34",,,,,,,"fee schedule","1095.34","1211.97",
"Pegaptanib sodium injection","J2503","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2447.72",,,,,,,"fee schedule","2447.72","2447.72",
"Pegademase bovine, 25 iu","J2504","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4990.1",,,,,,,"fee schedule","4990.1","4990.1",
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","45.96",,,,,,,"fee schedule","45.96","976.34",
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","45.96",,,,,,,"fee schedule","45.96","976.34",
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","45.96",,,,,,,"fee schedule","45.96","976.34",
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","976.34",,,,,,,"fee schedule","45.96","976.34",
"Pegloticase injection","J2507","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","8493.85",,,,,,,"fee schedule","8200.23","8784.12",
"Pegloticase injection","J2507","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8200.23",,,,,,,"fee schedule","8200.23","8784.12",
"Pegloticase injection","J2507","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","8578.79",,,,,,,"fee schedule","8200.23","8784.12",
"Pegloticase injection","J2507","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8200.23",,,,,,,"fee schedule","8200.23","8784.12",
"Pegloticase injection","J2507","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8200.23",,,,,,,"fee schedule","8200.23","8784.12",
"Pegloticase injection","J2507","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8784.12",,,,,,,"fee schedule","8200.23","8784.12",
"Pegunigalsidase alfa-iwxj","J2508","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","521.93",,,,,,,"fee schedule","521.93","521.93",
"Pegunigalsidase alfa-iwxj","J2508","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","521.93",,,,,,,"fee schedule","521.93","521.93",
"Pegunigalsidase alfa-iwxj","J2508","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","521.93",,,,,,,"fee schedule","521.93","521.93",
"Penicillin g procaine inj","J2510","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","100.61",,,,,,,"fee schedule","100.61","100.61",
"Pentobarbital sodium inj","J2515","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","126.29",,,,,,,"fee schedule","126.29","126.29",
"Penicillin g potassium inj","J2540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.78",,,,,,,"fee schedule","1.78","3.61",
"Penicillin g potassium inj","J2540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.78",,,,,,,"fee schedule","1.78","3.61",
"Penicillin g potassium inj","J2540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.78",,,,,,,"fee schedule","1.78","3.61",
"Penicillin g potassium inj","J2540","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.61",,,,,,,"fee schedule","1.78","3.61",
"Piperacillin/tazobactam","J2543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.57",,,,,,,"fee schedule","2.57","6.2",
"Piperacillin/tazobactam","J2543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.57",,,,,,,"fee schedule","2.57","6.2",
"Piperacillin/tazobactam","J2543","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.57",,,,,,,"fee schedule","2.57","6.2",
"Piperacillin/tazobactam","J2543","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.2",,,,,,,"fee schedule","2.57","6.2",
"Pentamidine non-comp unit","J2545","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","182.84",,,,,,,"fee schedule","182.84","418.07",
"Pentamidine non-comp unit","J2545","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","182.84",,,,,,,"fee schedule","182.84","418.07",
"Pentamidine non-comp unit","J2545","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","182.84",,,,,,,"fee schedule","182.84","418.07",
"Pentamidine non-comp unit","J2545","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","418.07",,,,,,,"fee schedule","182.84","418.07",
"Injection, peramivir","J2547","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.53",,,,,,,"fee schedule","5.53","5.53",
"Promethazine hcl injection","J2550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.62",,,,,,,"fee schedule","6.67","7.62",
"Promethazine hcl injection","J2550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.62",,,,,,,"fee schedule","6.67","7.62",
"Promethazine hcl injection","J2550","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.67",,,,,,,"fee schedule","6.67","7.62",
"Promethazine hcl injection","J2550","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.62",,,,,,,"fee schedule","6.67","7.62",
"Phenobarbital sodium inj","J2560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","67.7",,,,,,,"fee schedule","67.7","142.16",
"Phenobarbital sodium inj","J2560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","67.7",,,,,,,"fee schedule","67.7","142.16",
"Phenobarbital sodium inj","J2560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","67.7",,,,,,,"fee schedule","67.7","142.16",
"Phenobarbital sodium inj","J2560","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","142.16",,,,,,,"fee schedule","67.7","142.16",
"Plerixafor injection","J2562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","57.44",,,,,,,"fee schedule","57.44","1179.2",
"Plerixafor injection","J2562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","57.44",,,,,,,"fee schedule","57.44","1179.2",
"Plerixafor injection","J2562","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","57.44",,,,,,,"fee schedule","57.44","1179.2",
"Plerixafor injection","J2562","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1179.2",,,,,,,"fee schedule","57.44","1179.2",
"Oxytocin injection","J2590","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6",,,,,,,"fee schedule","6","6",
"Inj desmopressin acetate","J2597","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.32",,,,,,,"fee schedule","10.32","38.32",
"Inj desmopressin acetate","J2597","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.32",,,,,,,"fee schedule","10.32","38.32",
"Inj desmopressin acetate","J2597","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.32",,,,,,,"fee schedule","10.32","38.32",
"Inj desmopressin acetate","J2597","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","38.32",,,,,,,"fee schedule","10.32","38.32",
"Inj, vasopressin, 1 unit","J2598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.27",,,,,,,"fee schedule","3.27","3.27",
"Inj, vasopressin, 1 unit","J2598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.27",,,,,,,"fee schedule","3.27","3.27",
"Inj, vasopressin, 1 unit","J2598","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.27",,,,,,,"fee schedule","3.27","3.27",
"Inj vasopressin (am reg) 1 u","J2599","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.06",,,,,,,"fee schedule","3.06","3.06",
"Inj vasopressin (am reg) 1 u","J2599","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.06",,,,,,,"fee schedule","3.06","3.06",
"Inj vasopressin (am reg) 1 u","J2599","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.06",,,,,,,"fee schedule","3.06","3.06",
"Inj, vasopressin (baxter)","J2601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.05",,,,,,,"fee schedule","8.05","8.05",
"Inj, vasopressin (baxter)","J2601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.05",,,,,,,"fee schedule","8.05","8.05",
"Inj, vasopressin (baxter)","J2601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.05",,,,,,,"fee schedule","8.05","8.05",
"Inj progesterone per 50 MG","J2675","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.52",,,,,,,"fee schedule","1.52","5.73",
"Inj progesterone per 50 MG","J2675","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.52",,,,,,,"fee schedule","1.52","5.73",
"Inj progesterone per 50 MG","J2675","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.52",,,,,,,"fee schedule","1.52","5.73",
"Inj progesterone per 50 MG","J2675","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.73",,,,,,,"fee schedule","1.52","5.73",
"Inj fluphenazine hcl 1.25 mg","J2679","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.44",,,,,,,"fee schedule","16.44","16.44",
"Inj fluphenazine hcl 1.25 mg","J2679","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.44",,,,,,,"fee schedule","16.44","16.44",
"Inj fluphenazine hcl 1.25 mg","J2679","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.44",,,,,,,"fee schedule","16.44","16.44",
"Fluphenazine decanoate 25 MG","J2680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20.3",,,,,,,"fee schedule","20.3","38",
"Fluphenazine decanoate 25 MG","J2680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20.3",,,,,,,"fee schedule","20.3","38",
"Fluphenazine decanoate 25 MG","J2680","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","20.3",,,,,,,"fee schedule","20.3","38",
"Fluphenazine decanoate 25 MG","J2680","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","38",,,,,,,"fee schedule","20.3","38",
"Procainamide hcl injection","J2690","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","653.98",,,,,,,"fee schedule","329.95","653.98",
"Procainamide hcl injection","J2690","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","653.98",,,,,,,"fee schedule","329.95","653.98",
"Procainamide hcl injection","J2690","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","653.98",,,,,,,"fee schedule","329.95","653.98",
"Procainamide hcl injection","J2690","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","329.95",,,,,,,"fee schedule","329.95","653.98",
"Oxacillin sodium injeciton","J2700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.46",,,,,,,"fee schedule","1.46","3.75",
"Oxacillin sodium injeciton","J2700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.46",,,,,,,"fee schedule","1.46","3.75",
"Oxacillin sodium injeciton","J2700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.46",,,,,,,"fee schedule","1.46","3.75",
"Oxacillin sodium injeciton","J2700","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.75",,,,,,,"fee schedule","1.46","3.75",
"Inj, propofol, 10 mg","J2704","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.21",,,,,,,"fee schedule","0.21","0.37",
"Inj, propofol, 10 mg","J2704","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.21",,,,,,,"fee schedule","0.21","0.37",
"Inj, propofol, 10 mg","J2704","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.21",,,,,,,"fee schedule","0.21","0.37",
"Inj, propofol, 10 mg","J2704","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.37",,,,,,,"fee schedule","0.21","0.37",
"Neostigmine methylslfte inj","J2710","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.82",,,,,,,"fee schedule","10.82","10.82",
"Inj protamine sulfate/10 MG","J2720","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.22",,,,,,,"fee schedule","3.12","3.22",
"Inj protamine sulfate/10 MG","J2720","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.22",,,,,,,"fee schedule","3.12","3.22",
"Inj protamine sulfate/10 MG","J2720","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.22",,,,,,,"fee schedule","3.12","3.22",
"Inj protamine sulfate/10 MG","J2720","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.12",,,,,,,"fee schedule","3.12","3.22",
"Protein C concentrate","J2724","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","34.56",,,,,,,"fee schedule","34.56","51.06",
"Protein C concentrate","J2724","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","34.56",,,,,,,"fee schedule","34.56","51.06",
"Protein C concentrate","J2724","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","34.56",,,,,,,"fee schedule","34.56","51.06",
"Protein C concentrate","J2724","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","51.06",,,,,,,"fee schedule","34.56","51.06",
"Pralidoxime chloride inj","J2730","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","352.72",,,,,,,"fee schedule","352.72","352.72",
"Phentolaine mesylate inj","J2760","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1033.39",,,,,,,"fee schedule","1033.39","1284.12",
"Phentolaine mesylate inj","J2760","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1033.39",,,,,,,"fee schedule","1033.39","1284.12",
"Phentolaine mesylate inj","J2760","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1033.39",,,,,,,"fee schedule","1033.39","1284.12",
"Phentolaine mesylate inj","J2760","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1284.12",,,,,,,"fee schedule","1033.39","1284.12",
"Metoclopramide hcl injection","J2765","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.59",,,,,,,"fee schedule","2.59","4.21",
"Metoclopramide hcl injection","J2765","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.59",,,,,,,"fee schedule","2.59","4.21",
"Metoclopramide hcl injection","J2765","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.59",,,,,,,"fee schedule","2.59","4.21",
"Metoclopramide hcl injection","J2765","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.21",,,,,,,"fee schedule","2.59","4.21",
"Quinupristin/dalfopristin","J2770","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1411.83",,,,,,,"fee schedule","1411.83","1411.83",
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","79.86",,,,,,,"fee schedule","79.86","79.86",
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","79.86",,,,,,,"fee schedule","79.86","79.86",
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","79.86",,,,,,,"fee schedule","79.86","79.86",
"Ranibizumab injection","J2778","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","207.95",,,,,,,"fee schedule","207.95","1163.93",
"Ranibizumab injection","J2778","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","207.95",,,,,,,"fee schedule","207.95","1163.93",
"Ranibizumab injection","J2778","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","207.95",,,,,,,"fee schedule","207.95","1163.93",
"Ranibizumab injection","J2778","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1163.93",,,,,,,"fee schedule","207.95","1163.93",
"Inj, susvimo 0.1 mg","J2779","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","183.4",,,,,,,"fee schedule","183.4","183.4",
"Inj, susvimo 0.1 mg","J2779","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","183.4",,,,,,,"fee schedule","183.4","183.4",
"Inj, susvimo 0.1 mg","J2779","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","183.4",,,,,,,"fee schedule","183.4","183.4",
"Inj, pegcetacoplan, 1mg","J2781","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","331.17",,,,,,,"fee schedule","331.17","331.17",
"Inj, pegcetacoplan, 1mg","J2781","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","331.17",,,,,,,"fee schedule","331.17","331.17",
"Inj, pegcetacoplan, 1mg","J2781","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","331.17",,,,,,,"fee schedule","331.17","331.17",
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","247.12",,,,,,,"fee schedule","247.12","247.12",
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","247.12",,,,,,,"fee schedule","247.12","247.12",
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","247.12",,,,,,,"fee schedule","247.12","247.12",
"Rasburicase","J2783","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","852.05",,,,,,,"fee schedule","852.05","992.4",
"Rasburicase","J2783","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","852.05",,,,,,,"fee schedule","852.05","992.4",
"Rasburicase","J2783","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","852.05",,,,,,,"fee schedule","852.05","992.4",
"Rasburicase","J2783","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","992.4",,,,,,,"fee schedule","852.05","992.4",
"Regadenoson injection","J2785","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.15",,,,,,,"fee schedule","10.15","201.28",
"Regadenoson injection","J2785","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.15",,,,,,,"fee schedule","10.15","201.28",
"Regadenoson injection","J2785","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.15",,,,,,,"fee schedule","10.15","201.28",
"Regadenoson injection","J2785","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","201.28",,,,,,,"fee schedule","10.15","201.28",
"Injection, reslizumab, 1mg","J2786","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","30.2",,,,,,,"fee schedule","24.14","33.18",
"Injection, reslizumab, 1mg","J2786","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","24.14",,,,,,,"fee schedule","24.14","33.18",
"Injection, reslizumab, 1mg","J2786","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","29.91",,,,,,,"fee schedule","24.14","33.18",
"Injection, reslizumab, 1mg","J2786","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","24.14",,,,,,,"fee schedule","24.14","33.18",
"Injection, reslizumab, 1mg","J2786","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","24.14",,,,,,,"fee schedule","24.14","33.18",
"Injection, reslizumab, 1mg","J2786","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","33.18",,,,,,,"fee schedule","24.14","33.18",
"Riboflavin 5?phos opth<=3ml","J2787","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8696.29",,,,,,,"fee schedule","8696.29","8696.29",
"Rho d immune globulin 50 mcg","J2788","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","54.32",,,,,,,"fee schedule","54.32","88.57",
"Rho d immune globulin 50 mcg","J2788","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","54.32",,,,,,,"fee schedule","54.32","88.57",
"Rho d immune globulin 50 mcg","J2788","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","54.32",,,,,,,"fee schedule","54.32","88.57",
"Rho d immune globulin 50 mcg","J2788","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","88.57",,,,,,,"fee schedule","54.32","88.57",
"Rho d immune globulin inj","J2790","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","177.46",,,,,,,"fee schedule","177.46","262.96",
"Rho d immune globulin inj","J2790","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","177.46",,,,,,,"fee schedule","177.46","262.96",
"Rho d immune globulin inj","J2790","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","177.46",,,,,,,"fee schedule","177.46","262.96",
"Rho d immune globulin inj","J2790","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","262.96",,,,,,,"fee schedule","177.46","262.96",
"Rhophylac injection","J2791","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.23",,,,,,,"fee schedule","11.23","16.1",
"Rhophylac injection","J2791","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.23",,,,,,,"fee schedule","11.23","16.1",
"Rhophylac injection","J2791","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.23",,,,,,,"fee schedule","11.23","16.1",
"Rhophylac injection","J2791","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16.1",,,,,,,"fee schedule","11.23","16.1",
"Rho(D) immune globulin h, sd","J2792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","74.77",,,,,,,"fee schedule","74.77","97.44",
"Rho(D) immune globulin h, sd","J2792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","74.77",,,,,,,"fee schedule","74.77","97.44",
"Rho(D) immune globulin h, sd","J2792","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","74.77",,,,,,,"fee schedule","74.77","97.44",
"Rho(D) immune globulin h, sd","J2792","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","97.44",,,,,,,"fee schedule","74.77","97.44",
"Rilonacept injection","J2793","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","91.54",,,,,,,"fee schedule","91.54","91.54",
"Risperidone, long acting","J2794","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","24.15",,,,,,,"fee schedule","24.15","34.08",
"Risperidone, long acting","J2794","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","24.15",,,,,,,"fee schedule","24.15","34.08",
"Risperidone, long acting","J2794","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","24.15",,,,,,,"fee schedule","24.15","34.08",
"Risperidone, long acting","J2794","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","34.08",,,,,,,"fee schedule","24.15","34.08",
"Ropivacaine HCl injection","J2795","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.13",,,,,,,"fee schedule","0.13","0.27",
"Ropivacaine HCl injection","J2795","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.13",,,,,,,"fee schedule","0.13","0.27",
"Ropivacaine HCl injection","J2795","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.13",,,,,,,"fee schedule","0.13","0.27",
"Ropivacaine HCl injection","J2795","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.27",,,,,,,"fee schedule","0.13","0.27",
"Romiplostim injection","J2796","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","244.89",,,,,,,"fee schedule","242.46","244.89",
"Romiplostim injection","J2796","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","242.46",,,,,,,"fee schedule","242.46","244.89",
"Inj., rolapitant, 0.5 mg","J2797","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.18",,,,,,,"fee schedule","3.18","3.18",
"Inj., perseris, 0.5 mg","J2798","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","27.95",,,,,,,"fee schedule","27.95","33.12",
"Inj., perseris, 0.5 mg","J2798","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","27.95",,,,,,,"fee schedule","27.95","33.12",
"Inj., perseris, 0.5 mg","J2798","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","27.95",,,,,,,"fee schedule","27.95","33.12",
"Inj., perseris, 0.5 mg","J2798","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","33.12",,,,,,,"fee schedule","27.95","33.12",
"Inj, uzedy, 1 mg","J2799","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","56.63",,,,,,,"fee schedule","56.63","56.63",
"Inj, uzedy, 1 mg","J2799","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","56.63",,,,,,,"fee schedule","56.63","56.63",
"Inj, uzedy, 1 mg","J2799","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","56.63",,,,,,,"fee schedule","56.63","56.63",
"Methocarbamol injection","J2800","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14.63",,,,,,,"fee schedule","14.63","24.5",
"Methocarbamol injection","J2800","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14.63",,,,,,,"fee schedule","14.63","24.5",
"Methocarbamol injection","J2800","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14.63",,,,,,,"fee schedule","14.63","24.5",
"Methocarbamol injection","J2800","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","24.5",,,,,,,"fee schedule","14.63","24.5",
"Inj, romiplostim 1 microgram","J2802","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","24.19",,,,,,,"fee schedule","24.19","24.19",
"Inj, romiplostim 1 microgram","J2802","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","24.19",,,,,,,"fee schedule","24.19","24.19",
"Inj, romiplostim 1 microgram","J2802","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","24.19",,,,,,,"fee schedule","24.19","24.19",
"Inj, rifampin, 1 mg","J2804","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.33",,,,,,,"fee schedule","0.33","0.33",
"Inj, rifampin, 1 mg","J2804","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.33",,,,,,,"fee schedule","0.33","0.33",
"Inj, rifampin, 1 mg","J2804","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.33",,,,,,,"fee schedule","0.33","0.33",
"Sincalide injection","J2805","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","329.49",,,,,,,"fee schedule","329.49","380.48",
"Sincalide injection","J2805","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","329.49",,,,,,,"fee schedule","329.49","380.48",
"Sincalide injection","J2805","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","329.49",,,,,,,"fee schedule","329.49","380.48",
"Sincalide injection","J2805","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","380.48",,,,,,,"fee schedule","329.49","380.48",
"Inj theophylline per 40 MG","J2810","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.08",,,,,,,"fee schedule","3.08","3.08",
"Sargramostim injection","J2820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","137.73",,,,,,,"fee schedule","137.73","158.56",
"Sargramostim injection","J2820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","137.73",,,,,,,"fee schedule","137.73","158.56",
"Sargramostim injection","J2820","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","137.73",,,,,,,"fee schedule","137.73","158.56",
"Sargramostim injection","J2820","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","158.56",,,,,,,"fee schedule","137.73","158.56",
"Inj sebelipase alfa 1 mg","J2840","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1834.63",,,,,,,"fee schedule","1834.63","1834.63",
"Inj secretin synthetic human","J2850","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","117.9",,,,,,,"fee schedule","117.9","117.9",
"Injection, siltuximab","J2860","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","375.74",,,,,,,"fee schedule","375.74","384.57",
"Injection, siltuximab","J2860","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","375.74",,,,,,,"fee schedule","375.74","384.57",
"Injection, siltuximab","J2860","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","375.74",,,,,,,"fee schedule","375.74","384.57",
"Injection, siltuximab","J2860","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","384.57",,,,,,,"fee schedule","375.74","384.57",
"Inj sulfameth/trim 5 mg/1 mg","J2865","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.13",,,,,,,"fee schedule","0.13","0.13",
"Inj sulfameth/trim 5 mg/1 mg","J2865","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.13",,,,,,,"fee schedule","0.13","0.13",
"Inj sulfameth/trim 5 mg/1 mg","J2865","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.13",,,,,,,"fee schedule","0.13","0.13",
"Na ferric gluconate complex","J2916","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.67",,,,,,,"fee schedule","4.45","6.67",
"Na ferric gluconate complex","J2916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.45",,,,,,,"fee schedule","4.45","6.67",
"Na ferric gluconate complex","J2916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.45",,,,,,,"fee schedule","4.45","6.67",
"Na ferric gluconate complex","J2916","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.45",,,,,,,"fee schedule","4.45","6.67",
"Inj, methylpred sod succ 5mg","J2919","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.58",,,,,,,"fee schedule","0.58","3.01",
"Inj, methylpred sod succ 5mg","J2919","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.58",,,,,,,"fee schedule","0.58","3.01",
"Inj, methylpred sod succ 5mg","J2919","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.58",,,,,,,"fee schedule","0.58","3.01",
"Inj, methylpred sod succ 5mg","J2919","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.01",,,,,,,"fee schedule","0.58","3.01",
"Somatropin injection","J2941","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","285.22",,,,,,,"fee schedule","285.22","285.22",
"Reteplase injection","J2993","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4158.92",,,,,,,"fee schedule","4158.92","4158.92",
"Inj streptokinase /250000 IU","J2995","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","269.2",,,,,,,"fee schedule","269.2","269.2",
"Alteplase recombinant","J2997","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","210.36",,,,,,,"fee schedule","210.36","297.34",
"Alteplase recombinant","J2997","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","210.36",,,,,,,"fee schedule","210.36","297.34",
"Alteplase recombinant","J2997","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","210.36",,,,,,,"fee schedule","210.36","297.34",
"Alteplase recombinant","J2997","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","297.34",,,,,,,"fee schedule","210.36","297.34",
"Streptomycin injection","J3000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","58.85",,,,,,,"fee schedule","58.85","106.13",
"Streptomycin injection","J3000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","58.85",,,,,,,"fee schedule","58.85","106.13",
"Streptomycin injection","J3000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","58.85",,,,,,,"fee schedule","58.85","106.13",
"Streptomycin injection","J3000","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","106.13",,,,,,,"fee schedule","58.85","106.13",
"Fentanyl citrate injeciton","J3010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.93",,,,,,,"fee schedule","1.93","2.67",
"Fentanyl citrate injeciton","J3010","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.67",,,,,,,"fee schedule","1.93","2.67",
"Fentanyl citrate injeciton","J3010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.93",,,,,,,"fee schedule","1.93","2.67",
"Fentanyl citrate injeciton","J3010","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.93",,,,,,,"fee schedule","1.93","2.67",
"Sumatriptan succinate / 6 MG","J3030","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","561.72",,,,,,,"fee schedule","561.72","561.72",
"Inj., fremanezumab-vfrm 1 mg","J3031","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.93",,,,,,,"fee schedule","7.93","7.93",
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","44.44",,,,,,,"fee schedule","44.44","44.44",
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","44.44",,,,,,,"fee schedule","44.44","44.44",
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","44.44",,,,,,,"fee schedule","44.44","44.44",
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","160.99",,,,,,,"fee schedule","160.99","160.99",
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","160.99",,,,,,,"fee schedule","160.99","160.99",
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","160.99",,,,,,,"fee schedule","160.99","160.99",
"Inj, taliglucerace alfa 10 u","J3060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","93.48",,,,,,,"fee schedule","93.48","134.58",
"Inj, taliglucerace alfa 10 u","J3060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","93.48",,,,,,,"fee schedule","93.48","134.58",
"Inj, taliglucerace alfa 10 u","J3060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","93.48",,,,,,,"fee schedule","93.48","134.58",
"Inj, taliglucerace alfa 10 u","J3060","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","134.58",,,,,,,"fee schedule","93.48","134.58",
"Pentazocine injection","J3070","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","100.33",,,,,,,"fee schedule","100.33","100.33",
"Inj tedizolid phosphate","J3090","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.14",,,,,,,"fee schedule","4.14","5.3",
"Inj tedizolid phosphate","J3090","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.14",,,,,,,"fee schedule","4.14","5.3",
"Inj tedizolid phosphate","J3090","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.14",,,,,,,"fee schedule","4.14","5.3",
"Inj tedizolid phosphate","J3090","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.3",,,,,,,"fee schedule","4.14","5.3",
"Telavancin injection","J3095","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.31",,,,,,,"fee schedule","16.31","17.86",
"Telavancin injection","J3095","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.31",,,,,,,"fee schedule","16.31","17.86",
"Telavancin injection","J3095","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.31",,,,,,,"fee schedule","16.31","17.86",
"Telavancin injection","J3095","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17.86",,,,,,,"fee schedule","16.31","17.86",
"Tenecteplase injection","J3101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","373.65",,,,,,,"fee schedule","373.65","425.66",
"Tenecteplase injection","J3101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","373.65",,,,,,,"fee schedule","373.65","425.66",
"Tenecteplase injection","J3101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","373.65",,,,,,,"fee schedule","373.65","425.66",
"Tenecteplase injection","J3101","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","425.66",,,,,,,"fee schedule","373.65","425.66",
"Terbutaline sulfate inj","J3105","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.95",,,,,,,"fee schedule","3.25","6.95",
"Terbutaline sulfate inj","J3105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.25",,,,,,,"fee schedule","3.25","6.95",
"Terbutaline sulfate inj","J3105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.25",,,,,,,"fee schedule","3.25","6.95",
"Terbutaline sulfate inj","J3105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.25",,,,,,,"fee schedule","3.25","6.95",
"Teriparatide injection","J3110","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","203.18",,,,,,,"fee schedule","203.18","203.18",
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","27.88",,,,,,,"fee schedule","26.44","30.63",
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","27.6",,,,,,,"fee schedule","26.44","30.63",
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","26.44",,,,,,,"fee schedule","26.44","30.63",
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","26.44",,,,,,,"fee schedule","26.44","30.63",
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","26.44",,,,,,,"fee schedule","26.44","30.63",
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","30.63",,,,,,,"fee schedule","26.44","30.63",
"Inj testostero enanthate 1mg","J3121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.12",,,,,,,"fee schedule","0.12","0.16",
"Inj testostero enanthate 1mg","J3121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.12",,,,,,,"fee schedule","0.12","0.16",
"Inj testostero enanthate 1mg","J3121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.12",,,,,,,"fee schedule","0.12","0.16",
"Inj testostero enanthate 1mg","J3121","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.16",,,,,,,"fee schedule","0.12","0.16",
"Testosterone undecanoate 1mg","J3145","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.65",,,,,,,"fee schedule","4.65","5.1",
"Testosterone undecanoate 1mg","J3145","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.1",,,,,,,"fee schedule","4.65","5.1",
"Testosterone undecanoate 1mg","J3145","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.65",,,,,,,"fee schedule","4.65","5.1",
"Testosterone undecanoate 1mg","J3145","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.65",,,,,,,"fee schedule","4.65","5.1",
"Chlorpromazine hcl injection","J3230","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","66.79",,,,,,,"fee schedule","66.79","105.65",
"Chlorpromazine hcl injection","J3230","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","66.79",,,,,,,"fee schedule","66.79","105.65",
"Chlorpromazine hcl injection","J3230","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","66.79",,,,,,,"fee schedule","66.79","105.65",
"Chlorpromazine hcl injection","J3230","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","105.65",,,,,,,"fee schedule","66.79","105.65",
"Thyrotropin injection","J3240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4781.04",,,,,,,"fee schedule","4781.04","5766.7",
"Thyrotropin injection","J3240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4781.04",,,,,,,"fee schedule","4781.04","5766.7",
"Thyrotropin injection","J3240","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4781.04",,,,,,,"fee schedule","4781.04","5766.7",
"Thyrotropin injection","J3240","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5766.7",,,,,,,"fee schedule","4781.04","5766.7",
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","810.89",,,,,,,"fee schedule","810.89","810.89",
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","810.89",,,,,,,"fee schedule","810.89","810.89",
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","810.89",,,,,,,"fee schedule","810.89","810.89",
"Tigecycline injection","J3243","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.69",,,,,,,"fee schedule","0.69","5.5",
"Tigecycline injection","J3243","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.69",,,,,,,"fee schedule","0.69","5.5",
"Tigecycline injection","J3243","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.5",,,,,,,"fee schedule","0.69","5.5",
"Tigecycline injection","J3243","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.69",,,,,,,"fee schedule","0.69","5.5",
"Inj., tildrakizumab, 1 mg","J3245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","302.36",,,,,,,"fee schedule","302.36","457.3",
"Inj., tildrakizumab, 1 mg","J3245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","302.36",,,,,,,"fee schedule","302.36","457.3",
"Inj., tildrakizumab, 1 mg","J3245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","302.36",,,,,,,"fee schedule","302.36","457.3",
"Inj., tildrakizumab, 1 mg","J3245","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","457.3",,,,,,,"fee schedule","302.36","457.3",
"Tirofiban hcl","J3246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.16",,,,,,,"fee schedule","8.16","17.7",
"Tirofiban hcl","J3246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.16",,,,,,,"fee schedule","8.16","17.7",
"Tirofiban hcl","J3246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.16",,,,,,,"fee schedule","8.16","17.7",
"Tirofiban hcl","J3246","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17.7",,,,,,,"fee schedule","8.16","17.7",
"Inj secukinumab intrav 1mg","J3247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","40.77",,,,,,,"fee schedule","40.77","40.77",
"Inj secukinumab intrav 1mg","J3247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","40.77",,,,,,,"fee schedule","40.77","40.77",
"Inj secukinumab intrav 1mg","J3247","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","40.77",,,,,,,"fee schedule","40.77","40.77",
"Trimethobenzamide hcl inj","J3250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","115.09",,,,,,,"fee schedule","115.09","124.16",
"Trimethobenzamide hcl inj","J3250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","115.09",,,,,,,"fee schedule","115.09","124.16",
"Trimethobenzamide hcl inj","J3250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","115.09",,,,,,,"fee schedule","115.09","124.16",
"Trimethobenzamide hcl inj","J3250","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","124.16",,,,,,,"fee schedule","115.09","124.16",
"Tobramycin sulfate injection","J3260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.67",,,,,,,"fee schedule","3.67","13.46",
"Tobramycin sulfate injection","J3260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.67",,,,,,,"fee schedule","3.67","13.46",
"Tobramycin sulfate injection","J3260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.67",,,,,,,"fee schedule","3.67","13.46",
"Tobramycin sulfate injection","J3260","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13.46",,,,,,,"fee schedule","3.67","13.46",
"Tocilizumab injection","J3262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","16.76",,,,,,,"fee schedule","13.53","17.26",
"Tocilizumab injection","J3262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","16.93",,,,,,,"fee schedule","13.53","17.26",
"Tocilizumab injection","J3262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13.53",,,,,,,"fee schedule","13.53","17.26",
"Tocilizumab injection","J3262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13.53",,,,,,,"fee schedule","13.53","17.26",
"Tocilizumab injection","J3262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13.53",,,,,,,"fee schedule","13.53","17.26",
"Tocilizumab injection","J3262","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17.26",,,,,,,"fee schedule","13.53","17.26",
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","89.92",,,,,,,"fee schedule","89.92","89.92",
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","89.92",,,,,,,"fee schedule","89.92","89.92",
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","89.92",,,,,,,"fee schedule","89.92","89.92",
"Thiethylperazine maleate inj","J3280","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17.11",,,,,,,"fee schedule","17.11","17.11",
"Treprostinil injection","J3285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","130.72",,,,,,,"fee schedule","130.72","208.97",
"Treprostinil injection","J3285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","130.72",,,,,,,"fee schedule","130.72","208.97",
"Treprostinil injection","J3285","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","130.72",,,,,,,"fee schedule","130.72","208.97",
"Treprostinil injection","J3285","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","208.97",,,,,,,"fee schedule","130.72","208.97",
"Inj xipere 1 mg","J3299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","110.93",,,,,,,"fee schedule","110.93","110.93",
"Inj xipere 1 mg","J3299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","110.93",,,,,,,"fee schedule","110.93","110.93",
"Inj xipere 1 mg","J3299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","110.93",,,,,,,"fee schedule","110.93","110.93",
"Triamcinolone A inj PRS-free","J3300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","57.54",,,,,,,"fee schedule","13","57.54",
"Triamcinolone A inj PRS-free","J3300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","57.54",,,,,,,"fee schedule","13","57.54",
"Triamcinolone A inj PRS-free","J3300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","57.54",,,,,,,"fee schedule","13","57.54",
"Triamcinolone A inj PRS-free","J3300","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13",,,,,,,"fee schedule","13","57.54",
"Triamcinolone acet inj nos","J3301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2",,,,,,,"fee schedule","2","5.1",
"Triamcinolone acet inj nos","J3301","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.1",,,,,,,"fee schedule","2","5.1",
"Triamcinolone acet inj nos","J3301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2",,,,,,,"fee schedule","2","5.1",
"Triamcinolone acet inj nos","J3301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2",,,,,,,"fee schedule","2","5.1",
"Triamcinolone diacetate inj","J3302","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","1.22","1.22",
"Triamcinolone hexacetonl inj","J3303","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.58",,,,,,,"fee schedule","8.58","8.58",
"Inj triamcinolone ace xr 1mg","J3304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","41.42",,,,,,,"fee schedule","41.42","63.17",
"Inj triamcinolone ace xr 1mg","J3304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","41.42",,,,,,,"fee schedule","41.42","63.17",
"Inj triamcinolone ace xr 1mg","J3304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","41.42",,,,,,,"fee schedule","41.42","63.17",
"Inj triamcinolone ace xr 1mg","J3304","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","63.17",,,,,,,"fee schedule","41.42","63.17",
"Triptorelin pamoate","J3315","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1544.15",,,,,,,"fee schedule","910.09","1559.58",
"Triptorelin pamoate","J3315","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1559.58",,,,,,,"fee schedule","910.09","1559.58",
"Triptorelin pamoate","J3315","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1084.74",,,,,,,"fee schedule","910.09","1559.58",
"Triptorelin pamoate","J3315","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1084.74",,,,,,,"fee schedule","910.09","1559.58",
"Triptorelin pamoate","J3315","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1084.74",,,,,,,"fee schedule","910.09","1559.58",
"Triptorelin pamoate","J3315","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","910.09",,,,,,,"fee schedule","910.09","1559.58",
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8063.89",,,,,,,"fee schedule","8063.89","10062.31",
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8063.89",,,,,,,"fee schedule","8063.89","10062.31",
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8063.89",,,,,,,"fee schedule","8063.89","10062.31",
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10062.31",,,,,,,"fee schedule","8063.89","10062.31",
"Urofollitropin, 75 iu","J3355","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","509.15",,,,,,,"fee schedule","509.15","509.15",
"Ustekinumab sub cu inj, 1 mg","J3357","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","629.83",,,,,,,"fee schedule","629.83","629.83",
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","36.63",,,,,,,"fee schedule","29.46","40.26",
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","37.01",,,,,,,"fee schedule","29.46","40.26",
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","29.46",,,,,,,"fee schedule","29.46","40.26",
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","29.46",,,,,,,"fee schedule","29.46","40.26",
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","29.46",,,,,,,"fee schedule","29.46","40.26",
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","40.26",,,,,,,"fee schedule","29.46","40.26",
"Diazepam injection","J3360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13.31",,,,,,,"fee schedule","13.31","31.88",
"Diazepam injection","J3360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13.31",,,,,,,"fee schedule","13.31","31.88",
"Diazepam injection","J3360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13.31",,,,,,,"fee schedule","13.31","31.88",
"Diazepam injection","J3360","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","31.88",,,,,,,"fee schedule","13.31","31.88",
"Vancomycin hcl injection","J3370","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.48",,,,,,,"fee schedule","4.48","10.08",
"Vancomycin hcl injection","J3370","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.48",,,,,,,"fee schedule","4.48","10.08",
"Vancomycin hcl injection","J3370","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.48",,,,,,,"fee schedule","4.48","10.08",
"Vancomycin hcl injection","J3370","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.08",,,,,,,"fee schedule","4.48","10.08",
"Inj, vancomycin hcl (mylan)","J3371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14.51",,,,,,,"fee schedule","14.51","14.51",
"Inj, vancomycin hcl (mylan)","J3371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14.51",,,,,,,"fee schedule","14.51","14.51",
"Inj, vancomycin hcl (mylan)","J3371","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14.51",,,,,,,"fee schedule","14.51","14.51",
"Inj, vancomycin hcl (xellia)","J3372","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15.05",,,,,,,"fee schedule","15.05","15.05",
"Inj, vancomycin hcl (xellia)","J3372","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15.05",,,,,,,"fee schedule","15.05","15.05",
"Inj, vancomycin hcl (xellia)","J3372","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15.05",,,,,,,"fee schedule","15.05","15.05",
"Injection, vedolizumab","J3380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","62.36",,,,,,,"fee schedule","48.67","68.38",
"Injection, vedolizumab","J3380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","63",,,,,,,"fee schedule","48.67","68.38",
"Injection, vedolizumab","J3380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","48.67",,,,,,,"fee schedule","48.67","68.38",
"Injection, vedolizumab","J3380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","48.67",,,,,,,"fee schedule","48.67","68.38",
"Injection, vedolizumab","J3380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","48.67",,,,,,,"fee schedule","48.67","68.38",
"Injection, vedolizumab","J3380","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","68.38",,,,,,,"fee schedule","48.67","68.38",
"Velaglucerase alfa","J3385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1073.02",,,,,,,"fee schedule","861.03","1172.15",
"Velaglucerase alfa","J3385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","861.03",,,,,,,"fee schedule","861.03","1172.15",
"Velaglucerase alfa","J3385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1062.39",,,,,,,"fee schedule","861.03","1172.15",
"Velaglucerase alfa","J3385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","861.03",,,,,,,"fee schedule","861.03","1172.15",
"Velaglucerase alfa","J3385","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","861.03",,,,,,,"fee schedule","861.03","1172.15",
"Velaglucerase alfa","J3385","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1172.15",,,,,,,"fee schedule","861.03","1172.15",
"Verteporfin injection","J3396","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","26.49",,,,,,,"fee schedule","26.49","37.66",
"Verteporfin injection","J3396","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","26.49",,,,,,,"fee schedule","26.49","37.66",
"Verteporfin injection","J3396","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","26.49",,,,,,,"fee schedule","26.49","37.66",
"Verteporfin injection","J3396","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37.66",,,,,,,"fee schedule","26.49","37.66",
"Inj., vestronidase alfa-vjbk","J3397","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","741.57",,,,,,,"fee schedule","741.57","741.57",
"Inj luxturna 1 billion vec g","J3398","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9863.17",,,,,,,"fee schedule","9863.17","9863.17",
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2338.34",,,,,,,"fee schedule","2338.34","2338.34",
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2338.34",,,,,,,"fee schedule","2338.34","2338.34",
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2338.34",,,,,,,"fee schedule","2338.34","2338.34",
"Hydroxyzine hcl injection","J3410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","40.85",,,,,,,"fee schedule","21.46","40.85",
"Hydroxyzine hcl injection","J3410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","40.85",,,,,,,"fee schedule","21.46","40.85",
"Hydroxyzine hcl injection","J3410","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","40.85",,,,,,,"fee schedule","21.46","40.85",
"Hydroxyzine hcl injection","J3410","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21.46",,,,,,,"fee schedule","21.46","40.85",
"Thiamine hcl 100 mg","J3411","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.29",,,,,,,"fee schedule","4.04","10.29",
"Thiamine hcl 100 mg","J3411","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.04",,,,,,,"fee schedule","4.04","10.29",
"Thiamine hcl 100 mg","J3411","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.04",,,,,,,"fee schedule","4.04","10.29",
"Thiamine hcl 100 mg","J3411","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.04",,,,,,,"fee schedule","4.04","10.29",
"Pyridoxine hcl 100 mg","J3415","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","28.91",,,,,,,"fee schedule","26.88","28.91",
"Pyridoxine hcl 100 mg","J3415","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","28.91",,,,,,,"fee schedule","26.88","28.91",
"Pyridoxine hcl 100 mg","J3415","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","28.91",,,,,,,"fee schedule","26.88","28.91",
"Pyridoxine hcl 100 mg","J3415","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","26.88",,,,,,,"fee schedule","26.88","28.91",
"Vitamin b12 injection","J3420","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.53",,,,,,,"fee schedule","1.53","7.67",
"Vitamin b12 injection","J3420","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.53",,,,,,,"fee schedule","1.53","7.67",
"Vitamin b12 injection","J3420","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.53",,,,,,,"fee schedule","1.53","7.67",
"Vitamin b12 injection","J3420","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.67",,,,,,,"fee schedule","1.53","7.67",
"Inj, hydroxocobalamin","J3425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.02",,,,,,,"fee schedule","0.02","0.02",
"Inj, hydroxocobalamin","J3425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.02",,,,,,,"fee schedule","0.02","0.02",
"Inj, hydroxocobalamin","J3425","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.02",,,,,,,"fee schedule","0.02","0.02",
"Vitamin k phytonadione inj","J3430","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13.93",,,,,,,"fee schedule","5.62","13.93",
"Vitamin k phytonadione inj","J3430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.62",,,,,,,"fee schedule","5.62","13.93",
"Vitamin k phytonadione inj","J3430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.62",,,,,,,"fee schedule","5.62","13.93",
"Vitamin k phytonadione inj","J3430","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.62",,,,,,,"fee schedule","5.62","13.93",
"Injection, voriconazole","J3465","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.94",,,,,,,"fee schedule","2.44","5.94",
"Injection, voriconazole","J3465","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.44",,,,,,,"fee schedule","2.44","5.94",
"Injection, voriconazole","J3465","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.44",,,,,,,"fee schedule","2.44","5.94",
"Injection, voriconazole","J3465","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.44",,,,,,,"fee schedule","2.44","5.94",
"Hyaluronidase injection","J3470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","73.99",,,,,,,"fee schedule","73.99","227.02",
"Hyaluronidase injection","J3470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","73.99",,,,,,,"fee schedule","73.99","227.02",
"Hyaluronidase injection","J3470","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","73.99",,,,,,,"fee schedule","73.99","227.02",
"Hyaluronidase injection","J3470","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","227.02",,,,,,,"fee schedule","73.99","227.02",
"Ovine, up to 999 usp units","J3471","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.15",,,,,,,"fee schedule","1.15","1.47",
"Ovine, up to 999 usp units","J3471","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.15",,,,,,,"fee schedule","1.15","1.47",
"Ovine, up to 999 usp units","J3471","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.15",,,,,,,"fee schedule","1.15","1.47",
"Ovine, up to 999 usp units","J3471","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.47",,,,,,,"fee schedule","1.15","1.47",
"Ovine, 1000 USP units","J3472","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","402.54",,,,,,,"fee schedule","402.54","402.54",
"Hyaluronidase recombinant","J3473","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.84",,,,,,,"fee schedule","0.84","1.22",
"Hyaluronidase recombinant","J3473","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.84",,,,,,,"fee schedule","0.84","1.22",
"Hyaluronidase recombinant","J3473","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.84",,,,,,,"fee schedule","0.84","1.22",
"Hyaluronidase recombinant","J3473","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","0.84","1.22",
"Inj magnesium sulfate","J3475","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.14",,,,,,,"fee schedule","1.14","1.87",
"Inj magnesium sulfate","J3475","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.14",,,,,,,"fee schedule","1.14","1.87",
"Inj magnesium sulfate","J3475","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.14",,,,,,,"fee schedule","1.14","1.87",
"Inj magnesium sulfate","J3475","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.87",,,,,,,"fee schedule","1.14","1.87",
"Inj potassium chloride","J3480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.48",,,,,,,"fee schedule","0.42","0.48",
"Inj potassium chloride","J3480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.48",,,,,,,"fee schedule","0.42","0.48",
"Inj potassium chloride","J3480","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.48",,,,,,,"fee schedule","0.42","0.48",
"Inj potassium chloride","J3480","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.42",,,,,,,"fee schedule","0.42","0.48",
"Zidovudine","J3485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.48",,,,,,,"fee schedule","3.48","5.12",
"Zidovudine","J3485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.48",,,,,,,"fee schedule","3.48","5.12",
"Zidovudine","J3485","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.48",,,,,,,"fee schedule","3.48","5.12",
"Zidovudine","J3485","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.12",,,,,,,"fee schedule","3.48","5.12",
"Ziprasidone mesylate","J3486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.92",,,,,,,"fee schedule","11.92","57.07",
"Ziprasidone mesylate","J3486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.92",,,,,,,"fee schedule","11.92","57.07",
"Ziprasidone mesylate","J3486","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.92",,,,,,,"fee schedule","11.92","57.07",
"Ziprasidone mesylate","J3486","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","57.07",,,,,,,"fee schedule","11.92","57.07",
"Zoledronic acid 1mg","J3489","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","21.9",,,,,,,"fee schedule","21.9","45.07",
"Zoledronic acid 1mg","J3489","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","21.9",,,,,,,"fee schedule","21.9","45.07",
"Zoledronic acid 1mg","J3489","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","21.9",,,,,,,"fee schedule","21.9","45.07",
"Zoledronic acid 1mg","J3489","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","45.07",,,,,,,"fee schedule","21.9","45.07",
"Edetate disodium per 150 mg","J3520","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","1.22","1.22",
"Normal saline solution infus","J7030","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.77",,,,,,,"fee schedule","5.68","8.77",
"Normal saline solution infus","J7030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.68",,,,,,,"fee schedule","5.68","8.77",
"Normal saline solution infus","J7030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.68",,,,,,,"fee schedule","5.68","8.77",
"Normal saline solution infus","J7030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.68",,,,,,,"fee schedule","5.68","8.77",
"Normal saline solution infus","J7040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.84",,,,,,,"fee schedule","2.84","4.42",
"Normal saline solution infus","J7040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.84",,,,,,,"fee schedule","2.84","4.42",
"Normal saline solution infus","J7040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.84",,,,,,,"fee schedule","2.84","4.42",
"Normal saline solution infus","J7040","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.42",,,,,,,"fee schedule","2.84","4.42",
"5% dextrose/normal saline","J7042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.88",,,,,,,"fee schedule","2.88","3.47",
"5% dextrose/normal saline","J7042","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.47",,,,,,,"fee schedule","2.88","3.47",
"5% dextrose/normal saline","J7042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.88",,,,,,,"fee schedule","2.88","3.47",
"5% dextrose/normal saline","J7042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.88",,,,,,,"fee schedule","2.88","3.47",
"Normal saline solution infus","J7050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.42",,,,,,,"fee schedule","1.42","2.2",
"Normal saline solution infus","J7050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.42",,,,,,,"fee schedule","1.42","2.2",
"Normal saline solution infus","J7050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.42",,,,,,,"fee schedule","1.42","2.2",
"Normal saline solution infus","J7050","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.2",,,,,,,"fee schedule","1.42","2.2",
"5% dextrose/water","J7060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.19",,,,,,,"fee schedule","4.19","6.45",
"5% dextrose/water","J7060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.19",,,,,,,"fee schedule","4.19","6.45",
"5% dextrose/water","J7060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.19",,,,,,,"fee schedule","4.19","6.45",
"5% dextrose/water","J7060","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.45",,,,,,,"fee schedule","4.19","6.45",
"D5w infusion","J7070","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.37",,,,,,,"fee schedule","8.37","12.78",
"D5w infusion","J7070","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.37",,,,,,,"fee schedule","8.37","12.78",
"D5w infusion","J7070","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.37",,,,,,,"fee schedule","8.37","12.78",
"D5w infusion","J7070","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.78",,,,,,,"fee schedule","8.37","12.78",
"Dextran 40 infusion","J7100","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","107.94",,,,,,,"fee schedule","107.94","107.94",
"Ringers lactate infusion","J7120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.3",,,,,,,"fee schedule","5.3","8.17",
"Ringers lactate infusion","J7120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.3",,,,,,,"fee schedule","5.3","8.17",
"Ringers lactate infusion","J7120","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.17",,,,,,,"fee schedule","5.3","8.17",
"Ringers lactate infusion","J7120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.3",,,,,,,"fee schedule","5.3","8.17",
"5% dextrose in lac ringers","J7121","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16.54",,,,,,,"fee schedule","16.54","16.54",
"Hypertonic saline sol","J7131","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.35",,,,,,,"fee schedule","0.35","0.35",
"Prothrombin complex kcentra","J7168","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.82",,,,,,,"fee schedule","6.82","6.82",
"Inj andexxa, 10 mg","J7169","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","988.3",,,,,,,"fee schedule","988.3","988.3",
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","147.82",,,,,,,"fee schedule","119.56","160.39",
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","146.35",,,,,,,"fee schedule","119.56","160.39",
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","119.56",,,,,,,"fee schedule","119.56","160.39",
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","119.56",,,,,,,"fee schedule","119.56","160.39",
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","119.56",,,,,,,"fee schedule","119.56","160.39",
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","160.39",,,,,,,"fee schedule","119.56","160.39",
"Inj, adzynma, 10 iu","J7171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","79.39",,,,,,,"fee schedule","79.39","79.39",
"Inj, adzynma, 10 iu","J7171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","79.39",,,,,,,"fee schedule","79.39","79.39",
"Inj, adzynma, 10 iu","J7171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","79.39",,,,,,,"fee schedule","79.39","79.39",
"Inj, factor x, (human), 1iu","J7175","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","25.51",,,,,,,"fee schedule","21.93","25.51",
"Inj, factor x, (human), 1iu","J7175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","21.93",,,,,,,"fee schedule","21.93","25.51",
"Inj, factor x, (human), 1iu","J7175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","21.93",,,,,,,"fee schedule","21.93","25.51",
"Inj, factor x, (human), 1iu","J7175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","21.93",,,,,,,"fee schedule","21.93","25.51",
"Inj., fibryga, 1 mg","J7177","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.7",,,,,,,"fee schedule","2.53","3.7",
"Inj., fibryga, 1 mg","J7177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.53",,,,,,,"fee schedule","2.53","3.7",
"Inj., fibryga, 1 mg","J7177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.53",,,,,,,"fee schedule","2.53","3.7",
"Inj., fibryga, 1 mg","J7177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.53",,,,,,,"fee schedule","2.53","3.7",
"Human fibrinogen conc inj","J7178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.41",,,,,,,"fee schedule","3.41","4.21",
"Human fibrinogen conc inj","J7178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.41",,,,,,,"fee schedule","3.41","4.21",
"Human fibrinogen conc inj","J7178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.41",,,,,,,"fee schedule","3.41","4.21",
"Human fibrinogen conc inj","J7178","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.21",,,,,,,"fee schedule","3.41","4.21",
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.21",,,,,,,"fee schedule","4.21","6.27",
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.27",,,,,,,"fee schedule","4.21","6.27",
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.21",,,,,,,"fee schedule","4.21","6.27",
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.21",,,,,,,"fee schedule","4.21","6.27",
"Factor XIII anti-hem factor","J7180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","24.1",,,,,,,"fee schedule","24.1","29.83",
"Factor XIII anti-hem factor","J7180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","24.1",,,,,,,"fee schedule","24.1","29.83",
"Factor XIII anti-hem factor","J7180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","24.1",,,,,,,"fee schedule","24.1","29.83",
"Factor XIII anti-hem factor","J7180","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","29.83",,,,,,,"fee schedule","24.1","29.83",
"Factor xiii recomb a-subunit","J7181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","39.87",,,,,,,"fee schedule","39.87","51.94",
"Factor xiii recomb a-subunit","J7181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","39.87",,,,,,,"fee schedule","39.87","51.94",
"Factor xiii recomb a-subunit","J7181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","39.87",,,,,,,"fee schedule","39.87","51.94",
"Factor xiii recomb a-subunit","J7181","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","51.94",,,,,,,"fee schedule","39.87","51.94",
"Factor viii recomb novoeight","J7182","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.21",,,,,,,"fee schedule","3.21","4.39",
"Factor viii recomb novoeight","J7182","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.39",,,,,,,"fee schedule","3.21","4.39",
"Factor viii recomb novoeight","J7182","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.21",,,,,,,"fee schedule","3.21","4.39",
"Factor viii recomb novoeight","J7182","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.21",,,,,,,"fee schedule","3.21","4.39",
"Wilate injection","J7183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3.2",,,,,,,"fee schedule","2.94","3.61",
"Wilate injection","J7183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3.17",,,,,,,"fee schedule","2.94","3.61",
"Wilate injection","J7183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.94",,,,,,,"fee schedule","2.94","3.61",
"Wilate injection","J7183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.94",,,,,,,"fee schedule","2.94","3.61",
"Wilate injection","J7183","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.94",,,,,,,"fee schedule","2.94","3.61",
"Wilate injection","J7183","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.61",,,,,,,"fee schedule","2.94","3.61",
"Xyntha inj","J7185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3.8",,,,,,,"fee schedule","3.43","4.27",
"Xyntha inj","J7185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3.77",,,,,,,"fee schedule","3.43","4.27",
"Xyntha inj","J7185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.43",,,,,,,"fee schedule","3.43","4.27",
"Xyntha inj","J7185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.43",,,,,,,"fee schedule","3.43","4.27",
"Xyntha inj","J7185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.43",,,,,,,"fee schedule","3.43","4.27",
"Xyntha inj","J7185","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.27",,,,,,,"fee schedule","3.43","4.27",
"Antihemophilic viii/vwf comp","J7186","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3.45",,,,,,,"fee schedule","2.76","3.66",
"Antihemophilic viii/vwf comp","J7186","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3.49",,,,,,,"fee schedule","2.76","3.66",
"Antihemophilic viii/vwf comp","J7186","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.76",,,,,,,"fee schedule","2.76","3.66",
"Antihemophilic viii/vwf comp","J7186","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.66",,,,,,,"fee schedule","2.76","3.66",
"Antihemophilic viii/vwf comp","J7186","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.76",,,,,,,"fee schedule","2.76","3.66",
"Antihemophilic viii/vwf comp","J7186","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.76",,,,,,,"fee schedule","2.76","3.66",
"Humate-P, inj","J7187","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3.74",,,,,,,"fee schedule","3.33","4.1",
"Humate-P, inj","J7187","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3.77",,,,,,,"fee schedule","3.33","4.1",
"Humate-P, inj","J7187","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.33",,,,,,,"fee schedule","3.33","4.1",
"Humate-P, inj","J7187","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.33",,,,,,,"fee schedule","3.33","4.1",
"Humate-P, inj","J7187","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.33",,,,,,,"fee schedule","3.33","4.1",
"Humate-P, inj","J7187","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.1",,,,,,,"fee schedule","3.33","4.1",
"Factor viii recomb obizur","J7188","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.82",,,,,,,"fee schedule","7.43","10.82",
"Factor viii recomb obizur","J7188","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.43",,,,,,,"fee schedule","7.43","10.82",
"Factor viii recomb obizur","J7188","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.43",,,,,,,"fee schedule","7.43","10.82",
"Factor viii recomb obizur","J7188","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.43",,,,,,,"fee schedule","7.43","10.82",
"Factor viia","J7189","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","6.94",,,,,,,"fee schedule","5.81","7.36",
"Factor viia","J7189","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","7.01",,,,,,,"fee schedule","5.81","7.36",
"Factor viia","J7189","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.81",,,,,,,"fee schedule","5.81","7.36",
"Factor viia","J7189","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.81",,,,,,,"fee schedule","5.81","7.36",
"Factor viia","J7189","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.81",,,,,,,"fee schedule","5.81","7.36",
"Factor viia","J7189","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.36",,,,,,,"fee schedule","5.81","7.36",
"Factor viii","J7190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.57",,,,,,,"fee schedule","2.57","3.55",
"Factor viii","J7190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.57",,,,,,,"fee schedule","2.57","3.55",
"Factor viii","J7190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.57",,,,,,,"fee schedule","2.57","3.55",
"Factor viii","J7190","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.55",,,,,,,"fee schedule","2.57","3.55",
"Factor viii recombinant nos","J7192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4.14",,,,,,,"fee schedule","3.58","4.3",
"Factor viii recombinant nos","J7192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.58",,,,,,,"fee schedule","3.58","4.3",
"Factor viii recombinant nos","J7192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4.17",,,,,,,"fee schedule","3.58","4.3",
"Factor viii recombinant nos","J7192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.58",,,,,,,"fee schedule","3.58","4.3",
"Factor viii recombinant nos","J7192","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.3",,,,,,,"fee schedule","3.58","4.3",
"Factor viii recombinant nos","J7192","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.58",,,,,,,"fee schedule","3.58","4.3",
"Factor ix non-recombinant","J7193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.17",,,,,,,"fee schedule","3.17","3.93",
"Factor ix non-recombinant","J7193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.17",,,,,,,"fee schedule","3.17","3.93",
"Factor ix non-recombinant","J7193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.17",,,,,,,"fee schedule","3.17","3.93",
"Factor ix non-recombinant","J7193","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.93",,,,,,,"fee schedule","3.17","3.93",
"Factor ix complex","J7194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.81",,,,,,,"fee schedule","3.81","5.12",
"Factor ix complex","J7194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.81",,,,,,,"fee schedule","3.81","5.12",
"Factor ix complex","J7194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.81",,,,,,,"fee schedule","3.81","5.12",
"Factor ix complex","J7194","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.12",,,,,,,"fee schedule","3.81","5.12",
"Factor ix recombinant nos","J7195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4.74",,,,,,,"fee schedule","4.25","5.16",
"Factor ix recombinant nos","J7195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4.7",,,,,,,"fee schedule","4.25","5.16",
"Factor ix recombinant nos","J7195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.25",,,,,,,"fee schedule","4.25","5.16",
"Factor ix recombinant nos","J7195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.25",,,,,,,"fee schedule","4.25","5.16",
"Factor ix recombinant nos","J7195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.25",,,,,,,"fee schedule","4.25","5.16",
"Factor ix recombinant nos","J7195","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.16",,,,,,,"fee schedule","4.25","5.16",
"Antithrombin recombinant","J7196","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","350.4",,,,,,,"fee schedule","350.4","350.4",
"Antithrombin iii injection","J7197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.07",,,,,,,"fee schedule","9.07","12.26",
"Antithrombin iii injection","J7197","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.26",,,,,,,"fee schedule","9.07","12.26",
"Antithrombin iii injection","J7197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.07",,,,,,,"fee schedule","9.07","12.26",
"Antithrombin iii injection","J7197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.07",,,,,,,"fee schedule","9.07","12.26",
"Anti-inhibitor","J7198","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.51",,,,,,,"fee schedule","5.51","6.53",
"Anti-inhibitor","J7198","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.51",,,,,,,"fee schedule","5.51","6.53",
"Anti-inhibitor","J7198","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.51",,,,,,,"fee schedule","5.51","6.53",
"Anti-inhibitor","J7198","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.53",,,,,,,"fee schedule","5.51","6.53",
"Factor ix recombinan rixubis","J7200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.75",,,,,,,"fee schedule","3.75","4.64",
"Factor ix recombinan rixubis","J7200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.75",,,,,,,"fee schedule","3.75","4.64",
"Factor ix recombinan rixubis","J7200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.75",,,,,,,"fee schedule","3.75","4.64",
"Factor ix recombinan rixubis","J7200","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.64",,,,,,,"fee schedule","3.75","4.64",
"Factor ix alprolix recomb","J7201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","10.08",,,,,,,"fee schedule","8.15","10.61",
"Factor ix alprolix recomb","J7201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","9.99",,,,,,,"fee schedule","8.15","10.61",
"Factor ix alprolix recomb","J7201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.15",,,,,,,"fee schedule","8.15","10.61",
"Factor ix alprolix recomb","J7201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.15",,,,,,,"fee schedule","8.15","10.61",
"Factor ix alprolix recomb","J7201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.15",,,,,,,"fee schedule","8.15","10.61",
"Factor ix alprolix recomb","J7201","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.61",,,,,,,"fee schedule","8.15","10.61",
"Factor ix idelvion inj","J7202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.92",,,,,,,"fee schedule","11.92","15.08",
"Factor ix idelvion inj","J7202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.92",,,,,,,"fee schedule","11.92","15.08",
"Factor ix idelvion inj","J7202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.92",,,,,,,"fee schedule","11.92","15.08",
"Factor ix idelvion inj","J7202","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15.08",,,,,,,"fee schedule","11.92","15.08",
"Factor ix recomb gly rebinyn","J7203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.94",,,,,,,"fee schedule","9.94","13.49",
"Factor ix recomb gly rebinyn","J7203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.94",,,,,,,"fee schedule","9.94","13.49",
"Factor ix recomb gly rebinyn","J7203","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13.49",,,,,,,"fee schedule","9.94","13.49",
"Factor ix recomb gly rebinyn","J7203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.94",,,,,,,"fee schedule","9.94","13.49",
"Inj recombin esperoct per iu","J7204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.92",,,,,,,"fee schedule","4.92","4.92",
"Inj recombin esperoct per iu","J7204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.92",,,,,,,"fee schedule","4.92","4.92",
"Inj recombin esperoct per iu","J7204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.92",,,,,,,"fee schedule","4.92","4.92",
"Factor viii fc fusion recomb","J7205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","6.72",,,,,,,"fee schedule","5.34","7.14",
"Factor viii fc fusion recomb","J7205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","6.66",,,,,,,"fee schedule","5.34","7.14",
"Factor viii fc fusion recomb","J7205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.34",,,,,,,"fee schedule","5.34","7.14",
"Factor viii fc fusion recomb","J7205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.34",,,,,,,"fee schedule","5.34","7.14",
"Factor viii fc fusion recomb","J7205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.34",,,,,,,"fee schedule","5.34","7.14",
"Factor viii fc fusion recomb","J7205","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.14",,,,,,,"fee schedule","5.34","7.14",
"Factor viii pegylated recomb","J7207","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","5.72",,,,,,,"fee schedule","4.83","5.84",
"Factor viii pegylated recomb","J7207","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","5.66",,,,,,,"fee schedule","4.83","5.84",
"Factor viii pegylated recomb","J7207","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.83",,,,,,,"fee schedule","4.83","5.84",
"Factor viii pegylated recomb","J7207","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.83",,,,,,,"fee schedule","4.83","5.84",
"Factor viii pegylated recomb","J7207","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.83",,,,,,,"fee schedule","4.83","5.84",
"Factor viii pegylated recomb","J7207","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.84",,,,,,,"fee schedule","4.83","5.84",
"Inj. jivi 1 iu","J7208","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.64",,,,,,,"fee schedule","5.64","6.82",
"Inj. jivi 1 iu","J7208","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.64",,,,,,,"fee schedule","5.64","6.82",
"Inj. jivi 1 iu","J7208","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.64",,,,,,,"fee schedule","5.64","6.82",
"Inj. jivi 1 iu","J7208","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.82",,,,,,,"fee schedule","5.64","6.82",
"Factor viii nuwiq recomb 1iu","J7209","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3.86",,,,,,,"fee schedule","2.74","4.47",
"Factor viii nuwiq recomb 1iu","J7209","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3.91",,,,,,,"fee schedule","2.74","4.47",
"Factor viii nuwiq recomb 1iu","J7209","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.74",,,,,,,"fee schedule","2.74","4.47",
"Factor viii nuwiq recomb 1iu","J7209","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.74",,,,,,,"fee schedule","2.74","4.47",
"Factor viii nuwiq recomb 1iu","J7209","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.74",,,,,,,"fee schedule","2.74","4.47",
"Factor viii nuwiq recomb 1iu","J7209","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.47",,,,,,,"fee schedule","2.74","4.47",
"Inj, afstyla, 1 i.u.","J7210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","4.15",,,,,,,"fee schedule","3.48","4.62",
"Inj, afstyla, 1 i.u.","J7210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","4.18",,,,,,,"fee schedule","3.48","4.62",
"Inj, afstyla, 1 i.u.","J7210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.48",,,,,,,"fee schedule","3.48","4.62",
"Inj, afstyla, 1 i.u.","J7210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.48",,,,,,,"fee schedule","3.48","4.62",
"Inj, afstyla, 1 i.u.","J7210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.48",,,,,,,"fee schedule","3.48","4.62",
"Inj, afstyla, 1 i.u.","J7210","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.62",,,,,,,"fee schedule","3.48","4.62",
"Inj, kovaltry, 1 i.u.","J7211","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","3.75",,,,,,,"fee schedule","3.42","4.17",
"Inj, kovaltry, 1 i.u.","J7211","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.42",,,,,,,"fee schedule","3.42","4.17",
"Inj, kovaltry, 1 i.u.","J7211","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","3.78",,,,,,,"fee schedule","3.42","4.17",
"Inj, kovaltry, 1 i.u.","J7211","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.42",,,,,,,"fee schedule","3.42","4.17",
"Inj, kovaltry, 1 i.u.","J7211","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.42",,,,,,,"fee schedule","3.42","4.17",
"Inj, kovaltry, 1 i.u.","J7211","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.17",,,,,,,"fee schedule","3.42","4.17",
"Factor viia recomb sevenfact","J7212","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.49",,,,,,,"fee schedule","5.49","5.49",
"Factor viia recomb sevenfact","J7212","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.49",,,,,,,"fee schedule","5.49","5.49",
"Factor viia recomb sevenfact","J7212","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.49",,,,,,,"fee schedule","5.49","5.49",
"Inj, ixinity, 1 i.u.","J7213","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.42",,,,,,,"fee schedule","4.42","4.42",
"Inj, ixinity, 1 i.u.","J7213","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.42",,,,,,,"fee schedule","4.42","4.42",
"Inj, ixinity, 1 i.u.","J7213","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.42",,,,,,,"fee schedule","4.42","4.42",
"Altuviiio per factor viii iu","J7214","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.57",,,,,,,"fee schedule","10.57","10.57",
"Altuviiio per factor viii iu","J7214","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.57",,,,,,,"fee schedule","10.57","10.57",
"Altuviiio per factor viii iu","J7214","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.57",,,,,,,"fee schedule","10.57","10.57",
"Seg acet and eth estr yearly","J7294","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","661.67",,,,,,,"fee schedule","661.67","661.67",
"Eth estr and eton monthly","J7295","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","661.67",,,,,,,"fee schedule","661.67","661.67",
"Kyleena, 19.5 mg","J7296","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3879.29",,,,,,,"fee schedule","3879.29","3879.29",
"Liletta, 52 mg","J7297","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3201.31",,,,,,,"fee schedule","3201.31","3201.31",
"Mirena, 52 mg","J7298","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3879.29",,,,,,,"fee schedule","3879.29","3879.29",
"Intraut copper contraceptive","J7300","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3598.53",,,,,,,"fee schedule","3598.53","3598.53",
"Skyla, 13.5 mg","J7301","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3230.17",,,,,,,"fee schedule","3230.17","3230.17",
"Levonorgestrel implant sys","J7306","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1421.78",,,,,,,"fee schedule","1421.78","1421.78",
"Etonogestrel implant system","J7307","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3803.23",,,,,,,"fee schedule","3803.23","3803.23",
"Aminolevulinic acid hcl top","J7308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","907.15",,,,,,,"fee schedule","907.15","1340",
"Aminolevulinic acid hcl top","J7308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","907.15",,,,,,,"fee schedule","907.15","1340",
"Aminolevulinic acid hcl top","J7308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","907.15",,,,,,,"fee schedule","907.15","1340",
"Aminolevulinic acid hcl top","J7308","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1340",,,,,,,"fee schedule","907.15","1340",
"Ganciclovir long act implant","J7310","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","15527.11",,,,,,,"fee schedule","15527.11","15527.11",
"Fluocinolone acetonide implt","J7311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","782.08",,,,,,,"fee schedule","782.08","1150.8",
"Fluocinolone acetonide implt","J7311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","782.08",,,,,,,"fee schedule","782.08","1150.8",
"Fluocinolone acetonide implt","J7311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","782.08",,,,,,,"fee schedule","782.08","1150.8",
"Fluocinolone acetonide implt","J7311","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1150.8",,,,,,,"fee schedule","782.08","1150.8",
"Dexamethasone intra implant","J7312","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","472.04",,,,,,,"fee schedule","472.04","676.67",
"Dexamethasone intra implant","J7312","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","472.04",,,,,,,"fee schedule","472.04","676.67",
"Dexamethasone intra implant","J7312","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","472.04",,,,,,,"fee schedule","472.04","676.67",
"Dexamethasone intra implant","J7312","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","676.67",,,,,,,"fee schedule","472.04","676.67",
"Fluocinol acet intravit imp","J7313","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1128.76",,,,,,,"fee schedule","1128.76","1663.99",
"Fluocinol acet intravit imp","J7313","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1128.76",,,,,,,"fee schedule","1128.76","1663.99",
"Fluocinol acet intravit imp","J7313","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1128.76",,,,,,,"fee schedule","1128.76","1663.99",
"Fluocinol acet intravit imp","J7313","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1663.99",,,,,,,"fee schedule","1128.76","1663.99",
"Inj., yutiq, 0.01 mg","J7314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1206.51",,,,,,,"fee schedule","1206.51","1665.11",
"Inj., yutiq, 0.01 mg","J7314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1206.51",,,,,,,"fee schedule","1206.51","1665.11",
"Inj., yutiq, 0.01 mg","J7314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1206.51",,,,,,,"fee schedule","1206.51","1665.11",
"Inj., yutiq, 0.01 mg","J7314","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1665.11",,,,,,,"fee schedule","1206.51","1665.11",
"Inj, ocriplasmin, 0.125 mg","J7316","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3549.47",,,,,,,"fee schedule","3549.47","3549.47",
"Inj, durolane 1 mg","J7318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15.94",,,,,,,"fee schedule","15.94","58.42",
"Inj, durolane 1 mg","J7318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15.94",,,,,,,"fee schedule","15.94","58.42",
"Inj, durolane 1 mg","J7318","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15.94",,,,,,,"fee schedule","15.94","58.42",
"Inj, durolane 1 mg","J7318","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","58.42",,,,,,,"fee schedule","15.94","58.42",
"Genvisc 850, inj, 1mg","J7320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","14.52",,,,,,,"fee schedule","14.52","57.37",
"Genvisc 850, inj, 1mg","J7320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","14.52",,,,,,,"fee schedule","14.52","57.37",
"Genvisc 850, inj, 1mg","J7320","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","14.52",,,,,,,"fee schedule","14.52","57.37",
"Genvisc 850, inj, 1mg","J7320","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","57.37",,,,,,,"fee schedule","14.52","57.37",
"Hyalgan/supartz inj per dose","J7321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","170.11",,,,,,,"fee schedule","170.11","280.18",
"Hyalgan/supartz inj per dose","J7321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","170.11",,,,,,,"fee schedule","170.11","280.18",
"Hyalgan/supartz inj per dose","J7321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","170.11",,,,,,,"fee schedule","170.11","280.18",
"Hyalgan/supartz inj per dose","J7321","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","280.18",,,,,,,"fee schedule","170.11","280.18",
"Hymovis injection 1 mg","J7322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","40.26",,,,,,,"fee schedule","40.26","107.37",
"Hymovis injection 1 mg","J7322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","40.26",,,,,,,"fee schedule","40.26","107.37",
"Hymovis injection 1 mg","J7322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","40.26",,,,,,,"fee schedule","40.26","107.37",
"Hymovis injection 1 mg","J7322","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","107.37",,,,,,,"fee schedule","40.26","107.37",
"Euflexxa inj per dose","J7323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","296.03",,,,,,,"fee schedule","296.03","478.8",
"Euflexxa inj per dose","J7323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","296.03",,,,,,,"fee schedule","296.03","478.8",
"Euflexxa inj per dose","J7323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","296.03",,,,,,,"fee schedule","296.03","478.8",
"Euflexxa inj per dose","J7323","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","478.8",,,,,,,"fee schedule","296.03","478.8",
"Orthovisc inj per dose","J7324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","288.19",,,,,,,"fee schedule","288.19","457.81",
"Orthovisc inj per dose","J7324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","288.19",,,,,,,"fee schedule","288.19","457.81",
"Orthovisc inj per dose","J7324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","288.19",,,,,,,"fee schedule","288.19","457.81",
"Orthovisc inj per dose","J7324","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","457.81",,,,,,,"fee schedule","288.19","457.81",
"Synvisc or Synvisc-One","J7325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","21.28",,,,,,,"fee schedule","21.28","37.3",
"Synvisc or Synvisc-One","J7325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","21.28",,,,,,,"fee schedule","21.28","37.3",
"Synvisc or Synvisc-One","J7325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","21.28",,,,,,,"fee schedule","21.28","37.3",
"Synvisc or Synvisc-One","J7325","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37.3",,,,,,,"fee schedule","21.28","37.3",
"Gel-one","J7326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1238.5",,,,,,,"fee schedule","1238.5","3953.17",
"Gel-one","J7326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1238.5",,,,,,,"fee schedule","1238.5","3953.17",
"Gel-one","J7326","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1238.5",,,,,,,"fee schedule","1238.5","3953.17",
"Gel-one","J7326","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3953.17",,,,,,,"fee schedule","1238.5","3953.17",
"Monovisc inj per dose","J7327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1526.37",,,,,,,"fee schedule","1526.37","2508.39",
"Monovisc inj per dose","J7327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1526.37",,,,,,,"fee schedule","1526.37","2508.39",
"Monovisc inj per dose","J7327","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1526.37",,,,,,,"fee schedule","1526.37","2508.39",
"Monovisc inj per dose","J7327","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2508.39",,,,,,,"fee schedule","1526.37","2508.39",
"Gel-syn injection 0.1 mg","J7328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.36",,,,,,,"fee schedule","1.36","7.38",
"Gel-syn injection 0.1 mg","J7328","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.38",,,,,,,"fee schedule","1.36","7.38",
"Gel-syn injection 0.1 mg","J7328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.36",,,,,,,"fee schedule","1.36","7.38",
"Gel-syn injection 0.1 mg","J7328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.36",,,,,,,"fee schedule","1.36","7.38",
"Inj, trivisc 1 mg","J7329","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","12.85",,,,,,,"fee schedule","12.85","24.42",
"Inj, trivisc 1 mg","J7329","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","12.85",,,,,,,"fee schedule","12.85","24.42",
"Inj, trivisc 1 mg","J7329","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","12.85",,,,,,,"fee schedule","12.85","24.42",
"Inj, trivisc 1 mg","J7329","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","24.42",,,,,,,"fee schedule","12.85","24.42",
"Cultured chondrocytes implnt","J7330","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","146326.57",,,,,,,"fee schedule","146326.57","146326.57",
"Synojoynt, inj., 1 mg","J7331","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19.39",,,,,,,"fee schedule","19.39","19.41",
"Synojoynt, inj., 1 mg","J7331","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19.39",,,,,,,"fee schedule","19.39","19.41",
"Synojoynt, inj., 1 mg","J7331","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19.39",,,,,,,"fee schedule","19.39","19.41",
"Synojoynt, inj., 1 mg","J7331","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19.41",,,,,,,"fee schedule","19.39","19.41",
"Inj., triluron, 1 mg","J7332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","23.65",,,,,,,"fee schedule","23.65","87.89",
"Inj., triluron, 1 mg","J7332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","23.65",,,,,,,"fee schedule","23.65","87.89",
"Inj., triluron, 1 mg","J7332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","23.65",,,,,,,"fee schedule","23.65","87.89",
"Inj., triluron, 1 mg","J7332","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","87.89",,,,,,,"fee schedule","23.65","87.89",
"Capsaicin 8% patch","J7336","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.77",,,,,,,"fee schedule","7.77","11.01",
"Capsaicin 8% patch","J7336","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.77",,,,,,,"fee schedule","7.77","11.01",
"Capsaicin 8% patch","J7336","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.77",,,,,,,"fee schedule","7.77","11.01",
"Capsaicin 8% patch","J7336","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11.01",,,,,,,"fee schedule","7.77","11.01",
"Carbidopa levodopa ent 100ml","J7340","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","542.28",,,,,,,"fee schedule","542.28","752.83",
"Carbidopa levodopa ent 100ml","J7340","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","542.28",,,,,,,"fee schedule","542.28","752.83",
"Carbidopa levodopa ent 100ml","J7340","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","542.28",,,,,,,"fee schedule","542.28","752.83",
"Carbidopa levodopa ent 100ml","J7340","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","752.83",,,,,,,"fee schedule","542.28","752.83",
"Ciprofloxacin otic susp 6 mg","J7342","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","101.6",,,,,,,"fee schedule","101.6","101.6",
"Aminolevulinic acid, 10% gel","J7345","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.1",,,,,,,"fee schedule","4.1","4.86",
"Aminolevulinic acid, 10% gel","J7345","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.1",,,,,,,"fee schedule","4.1","4.86",
"Aminolevulinic acid, 10% gel","J7345","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.1",,,,,,,"fee schedule","4.1","4.86",
"Aminolevulinic acid, 10% gel","J7345","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.86",,,,,,,"fee schedule","4.1","4.86",
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","482.79",,,,,,,"fee schedule","482.79","482.79",
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","482.79",,,,,,,"fee schedule","482.79","482.79",
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","482.79",,,,,,,"fee schedule","482.79","482.79",
"Cantharidin top, applicator","J7354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1569.19",,,,,,,"fee schedule","1569.19","1569.19",
"Cantharidin top, applicator","J7354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1569.19",,,,,,,"fee schedule","1569.19","1569.19",
"Cantharidin top, applicator","J7354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1569.19",,,,,,,"fee schedule","1569.19","1569.19",
"Inj travoprost intra impl","J7355","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","447.15",,,,,,,"fee schedule","447.15","447.15",
"Inj travoprost intra impl","J7355","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","447.15",,,,,,,"fee schedule","447.15","447.15",
"Inj travoprost intra impl","J7355","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","447.15",,,,,,,"fee schedule","447.15","447.15",
"Mometasone sinus sinuva","J7402","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","26.09",,,,,,,"fee schedule","26.09","34.05",
"Mometasone sinus sinuva","J7402","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","26.09",,,,,,,"fee schedule","26.09","34.05",
"Mometasone sinus sinuva","J7402","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","26.09",,,,,,,"fee schedule","26.09","34.05",
"Mometasone sinus sinuva","J7402","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","34.05",,,,,,,"fee schedule","26.09","34.05",
"Azathioprine oral 50mg","J7500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.33",,,,,,,"fee schedule","2.33","2.34",
"Azathioprine oral 50mg","J7500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.33",,,,,,,"fee schedule","2.33","2.34",
"Azathioprine oral 50mg","J7500","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.33",,,,,,,"fee schedule","2.33","2.34",
"Azathioprine oral 50mg","J7500","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.34",,,,,,,"fee schedule","2.33","2.34",
"Azathioprine parenteral","J7501","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","767.66",,,,,,,"fee schedule","767.66","767.66",
"Cyclosporine oral 100 mg","J7502","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.65",,,,,,,"fee schedule","4.65","8.73",
"Cyclosporine oral 100 mg","J7502","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.65",,,,,,,"fee schedule","4.65","8.73",
"Cyclosporine oral 100 mg","J7502","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.65",,,,,,,"fee schedule","4.65","8.73",
"Cyclosporine oral 100 mg","J7502","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.73",,,,,,,"fee schedule","4.65","8.73",
"Tacrol envarsus ex rel oral","J7503","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.15",,,,,,,"fee schedule","4.15","4.59",
"Tacrol envarsus ex rel oral","J7503","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.15",,,,,,,"fee schedule","4.15","4.59",
"Tacrol envarsus ex rel oral","J7503","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.15",,,,,,,"fee schedule","4.15","4.59",
"Tacrol envarsus ex rel oral","J7503","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.59",,,,,,,"fee schedule","4.15","4.59",
"Lymphocyte immune globulin","J7504","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10065.47",,,,,,,"fee schedule","6961.2","10065.47",
"Lymphocyte immune globulin","J7504","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10065.47",,,,,,,"fee schedule","6961.2","10065.47",
"Lymphocyte immune globulin","J7504","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10065.47",,,,,,,"fee schedule","6961.2","10065.47",
"Lymphocyte immune globulin","J7504","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6961.2",,,,,,,"fee schedule","6961.2","10065.47",
"Monoclonal antibodies","J7505","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3285.32",,,,,,,"fee schedule","3285.32","3285.32",
"Tacrolimus imme rel oral 1mg","J7507","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.45",,,,,,,"fee schedule","0.45","2.52",
"Tacrolimus imme rel oral 1mg","J7507","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.45",,,,,,,"fee schedule","0.45","2.52",
"Tacrolimus imme rel oral 1mg","J7507","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.45",,,,,,,"fee schedule","0.45","2.52",
"Tacrolimus imme rel oral 1mg","J7507","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.52",,,,,,,"fee schedule","0.45","2.52",
"Tacrol astagraf ex rel oral","J7508","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.31",,,,,,,"fee schedule","1.31","1.61",
"Tacrol astagraf ex rel oral","J7508","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.31",,,,,,,"fee schedule","1.31","1.61",
"Tacrol astagraf ex rel oral","J7508","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.31",,,,,,,"fee schedule","1.31","1.61",
"Tacrol astagraf ex rel oral","J7508","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.61",,,,,,,"fee schedule","1.31","1.61",
"Methylprednisolone oral","J7509","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.56",,,,,,,"fee schedule","0.56","1.43",
"Methylprednisolone oral","J7509","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.56",,,,,,,"fee schedule","0.56","1.43",
"Methylprednisolone oral","J7509","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.56",,,,,,,"fee schedule","0.56","1.43",
"Methylprednisolone oral","J7509","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.43",,,,,,,"fee schedule","0.56","1.43",
"Prednisolone oral per 5 mg","J7510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.11",,,,,,,"fee schedule","0.35","1.11",
"Prednisolone oral per 5 mg","J7510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.11",,,,,,,"fee schedule","0.35","1.11",
"Prednisolone oral per 5 mg","J7510","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.11",,,,,,,"fee schedule","0.35","1.11",
"Prednisolone oral per 5 mg","J7510","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.35",,,,,,,"fee schedule","0.35","1.11",
"Antithymocyte globuln rabbit","J7511","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2160.5",,,,,,,"fee schedule","2160.5","2612.34",
"Antithymocyte globuln rabbit","J7511","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2160.5",,,,,,,"fee schedule","2160.5","2612.34",
"Antithymocyte globuln rabbit","J7511","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2160.5",,,,,,,"fee schedule","2160.5","2612.34",
"Antithymocyte globuln rabbit","J7511","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2612.34",,,,,,,"fee schedule","2160.5","2612.34",
"Prednisone ir or dr oral 1mg","J7512","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.01",,,,,,,"fee schedule","0.01","0.06",
"Prednisone ir or dr oral 1mg","J7512","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.01",,,,,,,"fee schedule","0.01","0.06",
"Prednisone ir or dr oral 1mg","J7512","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.01",,,,,,,"fee schedule","0.01","0.06",
"Prednisone ir or dr oral 1mg","J7512","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.06",,,,,,,"fee schedule","0.01","0.06",
"Daclizumab, parenteral","J7513","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1418.12",,,,,,,"fee schedule","1418.12","1418.12",
"Cyclosporine oral 25 mg","J7515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.71",,,,,,,"fee schedule","1.71","2.2",
"Cyclosporine oral 25 mg","J7515","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.2",,,,,,,"fee schedule","1.71","2.2",
"Cyclosporine oral 25 mg","J7515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.71",,,,,,,"fee schedule","1.71","2.2",
"Cyclosporine oral 25 mg","J7515","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.71",,,,,,,"fee schedule","1.71","2.2",
"Cyclosporin parenteral 250mg","J7516","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","164.22",,,,,,,"fee schedule","164.22","198.58",
"Cyclosporin parenteral 250mg","J7516","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","164.22",,,,,,,"fee schedule","164.22","198.58",
"Cyclosporin parenteral 250mg","J7516","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","164.22",,,,,,,"fee schedule","164.22","198.58",
"Cyclosporin parenteral 250mg","J7516","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","198.58",,,,,,,"fee schedule","164.22","198.58",
"Mycophenolate mofetil oral","J7517","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.35",,,,,,,"fee schedule","0.35","1.77",
"Mycophenolate mofetil oral","J7517","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.35",,,,,,,"fee schedule","0.35","1.77",
"Mycophenolate mofetil oral","J7517","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.35",,,,,,,"fee schedule","0.35","1.77",
"Mycophenolate mofetil oral","J7517","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.77",,,,,,,"fee schedule","0.35","1.77",
"Mycophenolic acid","J7518","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.87",,,,,,,"fee schedule","0.87","9.37",
"Mycophenolic acid","J7518","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.87",,,,,,,"fee schedule","0.87","9.37",
"Mycophenolic acid","J7518","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.87",,,,,,,"fee schedule","0.87","9.37",
"Mycophenolic acid","J7518","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.37",,,,,,,"fee schedule","0.87","9.37",
"Inj. mycophenolate mofetil","J7519","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.7",,,,,,,"fee schedule","0.7","0.7",
"Inj. mycophenolate mofetil","J7519","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.7",,,,,,,"fee schedule","0.7","0.7",
"Inj. mycophenolate mofetil","J7519","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.7",,,,,,,"fee schedule","0.7","0.7",
"Sirolimus, oral","J7520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.63",,,,,,,"fee schedule","2.63","19.02",
"Sirolimus, oral","J7520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.63",,,,,,,"fee schedule","2.63","19.02",
"Sirolimus, oral","J7520","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.63",,,,,,,"fee schedule","2.63","19.02",
"Sirolimus, oral","J7520","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19.02",,,,,,,"fee schedule","2.63","19.02",
"Tacrolim granules oral susp","J7521","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.07",,,,,,,"fee schedule","3.07","3.07",
"Tacrolim granules oral susp","J7521","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.07",,,,,,,"fee schedule","3.07","3.07",
"Tacrolim granules oral susp","J7521","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.07",,,,,,,"fee schedule","3.07","3.07",
"Tacrolimus injection","J7525","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","586.63",,,,,,,"fee schedule","586.63","717.92",
"Tacrolimus injection","J7525","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","586.63",,,,,,,"fee schedule","586.63","717.92",
"Tacrolimus injection","J7525","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","586.63",,,,,,,"fee schedule","586.63","717.92",
"Tacrolimus injection","J7525","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","717.92",,,,,,,"fee schedule","586.63","717.92",
"Oral everolimus","J7527","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.64",,,,,,,"fee schedule","4.64","30.42",
"Oral everolimus","J7527","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.64",,,,,,,"fee schedule","4.64","30.42",
"Oral everolimus","J7527","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.64",,,,,,,"fee schedule","4.64","30.42",
"Oral everolimus","J7527","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","30.42",,,,,,,"fee schedule","4.64","30.42",
"Ensifentrine inh 3 mg","J7601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","119.87",,,,,,,"fee schedule","119.87","119.87",
"Ensifentrine inh 3 mg","J7601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","119.87",,,,,,,"fee schedule","119.87","119.87",
"Ensifentrine inh 3 mg","J7601","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","119.87",,,,,,,"fee schedule","119.87","119.87",
"Arformoterol non-comp unit","J7605","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.58",,,,,,,"fee schedule","1.58","36.38",
"Arformoterol non-comp unit","J7605","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.58",,,,,,,"fee schedule","1.58","36.38",
"Arformoterol non-comp unit","J7605","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.58",,,,,,,"fee schedule","1.58","36.38",
"Arformoterol non-comp unit","J7605","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","36.38",,,,,,,"fee schedule","1.58","36.38",
"Formoterol fumarate, inh","J7606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.91",,,,,,,"fee schedule","3.91","40.75",
"Formoterol fumarate, inh","J7606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.91",,,,,,,"fee schedule","3.91","40.75",
"Formoterol fumarate, inh","J7606","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.91",,,,,,,"fee schedule","3.91","40.75",
"Formoterol fumarate, inh","J7606","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","40.75",,,,,,,"fee schedule","3.91","40.75",
"Acetylcysteine non-comp unit","J7608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19.41",,,,,,,"fee schedule","18.65","19.41",
"Acetylcysteine non-comp unit","J7608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19.41",,,,,,,"fee schedule","18.65","19.41",
"Acetylcysteine non-comp unit","J7608","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","18.65",,,,,,,"fee schedule","18.65","19.41",
"Acetylcysteine non-comp unit","J7608","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19.41",,,,,,,"fee schedule","18.65","19.41",
"Albuterol non-comp con","J7611","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.4",,,,,,,"fee schedule","0.4","0.88",
"Albuterol non-comp con","J7611","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.4",,,,,,,"fee schedule","0.4","0.88",
"Albuterol non-comp con","J7611","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.4",,,,,,,"fee schedule","0.4","0.88",
"Albuterol non-comp con","J7611","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.88",,,,,,,"fee schedule","0.4","0.88",
"Levalbuterol non-comp con","J7612","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.65",,,,,,,"fee schedule","0.65","1.05",
"Levalbuterol non-comp con","J7612","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.65",,,,,,,"fee schedule","0.65","1.05",
"Levalbuterol non-comp con","J7612","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.65",,,,,,,"fee schedule","0.65","1.05",
"Levalbuterol non-comp con","J7612","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.05",,,,,,,"fee schedule","0.65","1.05",
"Albuterol non-comp unit","J7613","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.13",,,,,,,"fee schedule","0.13","0.18",
"Albuterol non-comp unit","J7613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.18",,,,,,,"fee schedule","0.13","0.18",
"Albuterol non-comp unit","J7613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.18",,,,,,,"fee schedule","0.13","0.18",
"Albuterol non-comp unit","J7613","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.18",,,,,,,"fee schedule","0.13","0.18",
"Levalbuterol non-comp unit","J7614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.2",,,,,,,"fee schedule","0.2","0.21",
"Levalbuterol non-comp unit","J7614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.2",,,,,,,"fee schedule","0.2","0.21",
"Levalbuterol non-comp unit","J7614","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.2",,,,,,,"fee schedule","0.2","0.21",
"Levalbuterol non-comp unit","J7614","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.21",,,,,,,"fee schedule","0.2","0.21",
"Levalbuterol comp unit","J7615","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.36",,,,,,,"fee schedule","7.36","7.36",
"Albuterol ipratrop non-comp","J7620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.45",,,,,,,"fee schedule","0.42","0.45",
"Albuterol ipratrop non-comp","J7620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.45",,,,,,,"fee schedule","0.42","0.45",
"Albuterol ipratrop non-comp","J7620","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.45",,,,,,,"fee schedule","0.42","0.45",
"Albuterol ipratrop non-comp","J7620","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.42",,,,,,,"fee schedule","0.42","0.45",
"Budesonide non-comp unit","J7626","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.74",,,,,,,"fee schedule","2.74","5.89",
"Budesonide non-comp unit","J7626","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.74",,,,,,,"fee schedule","2.74","5.89",
"Budesonide non-comp unit","J7626","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.74",,,,,,,"fee schedule","2.74","5.89",
"Budesonide non-comp unit","J7626","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.89",,,,,,,"fee schedule","2.74","5.89",
"Budesonide comp unit","J7627","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17.11",,,,,,,"fee schedule","17.11","17.11",
"Cromolyn sodium noncomp unit","J7631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.67",,,,,,,"fee schedule","0.67","7.24",
"Cromolyn sodium noncomp unit","J7631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.67",,,,,,,"fee schedule","0.67","7.24",
"Cromolyn sodium noncomp unit","J7631","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.67",,,,,,,"fee schedule","0.67","7.24",
"Cromolyn sodium noncomp unit","J7631","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.24",,,,,,,"fee schedule","0.67","7.24",
"Cromolyn sodium comp unit","J7632","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.22",,,,,,,"fee schedule","1.22","1.22",
"Dornase alfa non-comp unit","J7639","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","123.25",,,,,,,"fee schedule","123.25","162.02",
"Dornase alfa non-comp unit","J7639","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","123.25",,,,,,,"fee schedule","123.25","162.02",
"Dornase alfa non-comp unit","J7639","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","123.25",,,,,,,"fee schedule","123.25","162.02",
"Dornase alfa non-comp unit","J7639","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","162.02",,,,,,,"fee schedule","123.25","162.02",
"Flunisolide comp unit","J7641","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","37.93",,,,,,,"fee schedule","37.93","37.93",
"Ipratropium bromide non-comp","J7644","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.83",,,,,,,"fee schedule","0.72","0.83",
"Ipratropium bromide non-comp","J7644","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.83",,,,,,,"fee schedule","0.72","0.83",
"Ipratropium bromide non-comp","J7644","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.83",,,,,,,"fee schedule","0.72","0.83",
"Ipratropium bromide non-comp","J7644","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.72",,,,,,,"fee schedule","0.72","0.83",
"Mannitol for inhaler","J7665","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4",,,,,,,"fee schedule","4","4",
"Methacholine chloride, neb","J7674","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.75",,,,,,,"fee schedule","2.58","3.75",
"Methacholine chloride, neb","J7674","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.75",,,,,,,"fee schedule","2.58","3.75",
"Methacholine chloride, neb","J7674","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.75",,,,,,,"fee schedule","2.58","3.75",
"Methacholine chloride, neb","J7674","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.58",,,,,,,"fee schedule","2.58","3.75",
"Revefenacin inh non-com 1mcg","J7677","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.45",,,,,,,"fee schedule","0.45","0.8",
"Revefenacin inh non-com 1mcg","J7677","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.45",,,,,,,"fee schedule","0.45","0.8",
"Revefenacin inh non-com 1mcg","J7677","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.45",,,,,,,"fee schedule","0.45","0.8",
"Revefenacin inh non-com 1mcg","J7677","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.8",,,,,,,"fee schedule","0.45","0.8",
"Terbutaline sulf comp con","J7680","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","47.71",,,,,,,"fee schedule","47.71","47.71",
"Terbutaline sulf comp unit","J7681","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","47.71",,,,,,,"fee schedule","47.71","47.71",
"Tobramycin non-comp unit","J7682","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","34.05",,,,,,,"fee schedule","34.05","116.12",
"Tobramycin non-comp unit","J7682","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","34.05",,,,,,,"fee schedule","34.05","116.12",
"Tobramycin non-comp unit","J7682","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","34.05",,,,,,,"fee schedule","34.05","116.12",
"Tobramycin non-comp unit","J7682","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","116.12",,,,,,,"fee schedule","34.05","116.12",
"Triamcinolone comp con","J7683","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","17.11",,,,,,,"fee schedule","17.11","17.11",
"Tobramycin comp unit","J7685","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","219.03",,,,,,,"fee schedule","219.03","219.03",
"Treprostinil, non-comp unit","J7686","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1748.91",,,,,,,"fee schedule","1748.91","2078.17",
"Treprostinil, non-comp unit","J7686","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1748.91",,,,,,,"fee schedule","1748.91","2078.17",
"Treprostinil, non-comp unit","J7686","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1748.91",,,,,,,"fee schedule","1748.91","2078.17",
"Treprostinil, non-comp unit","J7686","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2078.17",,,,,,,"fee schedule","1748.91","2078.17",
"Oral aprepitant","J8501","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16.04",,,,,,,"fee schedule","7","16.04",
"Oral aprepitant","J8501","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7",,,,,,,"fee schedule","7","16.04",
"Oral aprepitant","J8501","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7",,,,,,,"fee schedule","7","16.04",
"Oral aprepitant","J8501","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7",,,,,,,"fee schedule","7","16.04",
"Oral busulfan","J8510","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","80.89",,,,,,,"fee schedule","80.89","80.89",
"Cabergoline, oral 0.25mg","J8515","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","60.39",,,,,,,"fee schedule","60.39","60.39",
"Capecitabine, oral, 50 mg","J8522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.15",,,,,,,"fee schedule","0.15","0.15",
"Capecitabine, oral, 50 mg","J8522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.15",,,,,,,"fee schedule","0.15","0.15",
"Capecitabine, oral, 50 mg","J8522","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.15",,,,,,,"fee schedule","0.15","0.15",
"Cyclophosphamide oral 25 MG","J8530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.62",,,,,,,"fee schedule","2.62","8.3",
"Cyclophosphamide oral 25 MG","J8530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.62",,,,,,,"fee schedule","2.62","8.3",
"Cyclophosphamide oral 25 MG","J8530","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.62",,,,,,,"fee schedule","2.62","8.3",
"Cyclophosphamide oral 25 MG","J8530","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.3",,,,,,,"fee schedule","2.62","8.3",
"Oral dexamethasone","J8540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.14",,,,,,,"fee schedule","0.14","0.24",
"Oral dexamethasone","J8540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.14",,,,,,,"fee schedule","0.14","0.24",
"Oral dexamethasone","J8540","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.14",,,,,,,"fee schedule","0.14","0.24",
"Oral dexamethasone","J8540","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.24",,,,,,,"fee schedule","0.14","0.24",
"Etoposide oral 50 mg","J8560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","175.85",,,,,,,"fee schedule","175.85","252.96",
"Etoposide oral 50 mg","J8560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","175.85",,,,,,,"fee schedule","175.85","252.96",
"Etoposide oral 50 mg","J8560","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","175.85",,,,,,,"fee schedule","175.85","252.96",
"Etoposide oral 50 mg","J8560","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","252.96",,,,,,,"fee schedule","175.85","252.96",
"Gefitinib oral","J8565","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1056.32",,,,,,,"fee schedule","1056.32","1056.32",
"Melphalan oral 2 MG","J8600","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","43.74",,,,,,,"fee schedule","43.74","43.74",
"Methotrexate oral 2.5 MG","J8610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.46",,,,,,,"fee schedule","0.46","0.78",
"Methotrexate oral 2.5 MG","J8610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.46",,,,,,,"fee schedule","0.46","0.78",
"Methotrexate oral 2.5 MG","J8610","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.46",,,,,,,"fee schedule","0.46","0.78",
"Methotrexate oral 2.5 MG","J8610","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.78",,,,,,,"fee schedule","0.46","0.78",
"Nabilone oral","J8650","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","57.51",,,,,,,"fee schedule","57.51","57.51",
"Netupitant palonosetron oral","J8655","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","940.72",,,,,,,"fee schedule","752.16","940.72",
"Netupitant palonosetron oral","J8655","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","940.72",,,,,,,"fee schedule","752.16","940.72",
"Netupitant palonosetron oral","J8655","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","940.72",,,,,,,"fee schedule","752.16","940.72",
"Netupitant palonosetron oral","J8655","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","752.16",,,,,,,"fee schedule","752.16","940.72",
"Rolapitant, oral, 1mg","J8670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.11",,,,,,,"fee schedule","4.11","8.77",
"Rolapitant, oral, 1mg","J8670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.11",,,,,,,"fee schedule","4.11","8.77",
"Rolapitant, oral, 1mg","J8670","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.77",,,,,,,"fee schedule","4.11","8.77",
"Rolapitant, oral, 1mg","J8670","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.11",,,,,,,"fee schedule","4.11","8.77",
"Temozolomide","J8700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.88",,,,,,,"fee schedule","0.88","2.15",
"Temozolomide","J8700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.88",,,,,,,"fee schedule","0.88","2.15",
"Temozolomide","J8700","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.88",,,,,,,"fee schedule","0.88","2.15",
"Temozolomide","J8700","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.15",,,,,,,"fee schedule","0.88","2.15",
"Topotecan oral","J8705","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","287.27",,,,,,,"fee schedule","287.27","351.55",
"Topotecan oral","J8705","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","287.27",,,,,,,"fee schedule","287.27","351.55",
"Topotecan oral","J8705","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","287.27",,,,,,,"fee schedule","287.27","351.55",
"Topotecan oral","J8705","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","351.55",,,,,,,"fee schedule","287.27","351.55",
"Doxorubicin hcl injection","J9000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.25",,,,,,,"fee schedule","7.25","10.16",
"Doxorubicin hcl injection","J9000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.25",,,,,,,"fee schedule","7.25","10.16",
"Doxorubicin hcl injection","J9000","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.25",,,,,,,"fee schedule","7.25","10.16",
"Doxorubicin hcl injection","J9000","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.16",,,,,,,"fee schedule","7.25","10.16",
"Aldesleukin injection","J9015","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16831.89",,,,,,,"fee schedule","16831.89","16831.89",
"Arsenic trioxide injection","J9017","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.02",,,,,,,"fee schedule","11.02","102.49",
"Arsenic trioxide injection","J9017","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.02",,,,,,,"fee schedule","11.02","102.49",
"Arsenic trioxide injection","J9017","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.02",,,,,,,"fee schedule","11.02","102.49",
"Arsenic trioxide injection","J9017","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","102.49",,,,,,,"fee schedule","11.02","102.49",
"Erwinaze injection","J9019","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1406.44",,,,,,,"fee schedule","1406.44","1406.44",
"Asparaginase, nos","J9020","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","193.33",,,,,,,"fee schedule","193.33","193.33",
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","125.07",,,,,,,"fee schedule","125.07","125.07",
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","125.07",,,,,,,"fee schedule","125.07","125.07",
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","125.07",,,,,,,"fee schedule","125.07","125.07",
"Inj, atezolizumab,10 mg","J9022","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","239.62",,,,,,,"fee schedule","205.61","262.41",
"Inj, atezolizumab,10 mg","J9022","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","242.01",,,,,,,"fee schedule","205.61","262.41",
"Inj, atezolizumab,10 mg","J9022","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","205.61",,,,,,,"fee schedule","205.61","262.41",
"Inj, atezolizumab,10 mg","J9022","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","205.61",,,,,,,"fee schedule","205.61","262.41",
"Inj, atezolizumab,10 mg","J9022","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","205.61",,,,,,,"fee schedule","205.61","262.41",
"Inj, atezolizumab,10 mg","J9022","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","262.41",,,,,,,"fee schedule","205.61","262.41",
"Injection, avelumab, 10 mg","J9023","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","264.15",,,,,,,"fee schedule","223.42","285.59",
"Injection, avelumab, 10 mg","J9023","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","261.53",,,,,,,"fee schedule","223.42","285.59",
"Injection, avelumab, 10 mg","J9023","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","223.42",,,,,,,"fee schedule","223.42","285.59",
"Injection, avelumab, 10 mg","J9023","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","223.42",,,,,,,"fee schedule","223.42","285.59",
"Injection, avelumab, 10 mg","J9023","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","223.42",,,,,,,"fee schedule","223.42","285.59",
"Injection, avelumab, 10 mg","J9023","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","285.59",,,,,,,"fee schedule","223.42","285.59",
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","71.01",,,,,,,"fee schedule","71.01","71.01",
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","71.01",,,,,,,"fee schedule","71.01","71.01",
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","71.01",,,,,,,"fee schedule","71.01","71.01",
"Azacitidine injection","J9025","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.72",,,,,,,"fee schedule","0.72","3.02",
"Azacitidine injection","J9025","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.72",,,,,,,"fee schedule","0.72","3.02",
"Azacitidine injection","J9025","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.02",,,,,,,"fee schedule","0.72","3.02",
"Azacitidine injection","J9025","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.72",,,,,,,"fee schedule","0.72","3.02",
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3612.76",,,,,,,"fee schedule","3612.76","3612.76",
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3612.76",,,,,,,"fee schedule","3612.76","3612.76",
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3612.76",,,,,,,"fee schedule","3612.76","3612.76",
"Clofarabine injection","J9027","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36.81",,,,,,,"fee schedule","36.81","218.94",
"Clofarabine injection","J9027","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","36.81",,,,,,,"fee schedule","36.81","218.94",
"Clofarabine injection","J9027","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","36.81",,,,,,,"fee schedule","36.81","218.94",
"Clofarabine injection","J9027","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","218.94",,,,,,,"fee schedule","36.81","218.94",
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","217.54",,,,,,,"fee schedule","217.54","217.54",
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","217.54",,,,,,,"fee schedule","217.54","217.54",
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","217.54",,,,,,,"fee schedule","217.54","217.54",
"Inj, adstiladrin, per tx dos","J9029","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","145441.9",,,,,,,"fee schedule","145441.9","145441.9",
"Inj, adstiladrin, per tx dos","J9029","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","145441.9",,,,,,,"fee schedule","145441.9","145441.9",
"Inj, adstiladrin, per tx dos","J9029","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","145441.9",,,,,,,"fee schedule","145441.9","145441.9",
"Bcg live intravesical 1mg","J9030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.22",,,,,,,"fee schedule","7.22","9.53",
"Bcg live intravesical 1mg","J9030","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.53",,,,,,,"fee schedule","7.22","9.53",
"Bcg live intravesical 1mg","J9030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.22",,,,,,,"fee schedule","7.22","9.53",
"Bcg live intravesical 1mg","J9030","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.22",,,,,,,"fee schedule","7.22","9.53",
"Injection, belinostat, 10mg","J9032","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","117.11",,,,,,,"fee schedule","117.11","139.61",
"Injection, belinostat, 10mg","J9032","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","117.11",,,,,,,"fee schedule","117.11","139.61",
"Injection, belinostat, 10mg","J9032","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","117.11",,,,,,,"fee schedule","117.11","139.61",
"Injection, belinostat, 10mg","J9032","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","139.61",,,,,,,"fee schedule","117.11","139.61",
"Inj., treanda 1 mg","J9033","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.85",,,,,,,"fee schedule","2.85","88.87",
"Inj., treanda 1 mg","J9033","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.85",,,,,,,"fee schedule","2.85","88.87",
"Inj., treanda 1 mg","J9033","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.85",,,,,,,"fee schedule","2.85","88.87",
"Inj., treanda 1 mg","J9033","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","88.87",,,,,,,"fee schedule","2.85","88.87",
"Inj., bendeka 1 mg","J9034","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","31.24",,,,,,,"fee schedule","31.24","71.8",
"Inj., bendeka 1 mg","J9034","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","31.24",,,,,,,"fee schedule","31.24","71.8",
"Inj., bendeka 1 mg","J9034","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","31.24",,,,,,,"fee schedule","31.24","71.8",
"Inj., bendeka 1 mg","J9034","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","71.8",,,,,,,"fee schedule","31.24","71.8",
"Bevacizumab injection","J9035","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","167.27",,,,,,,"fee schedule","167.27","269.74",
"Bevacizumab injection","J9035","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","167.27",,,,,,,"fee schedule","167.27","269.74",
"Bevacizumab injection","J9035","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","167.27",,,,,,,"fee schedule","167.27","269.74",
"Bevacizumab injection","J9035","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","269.74",,,,,,,"fee schedule","167.27","269.74",
"Inj. belrapzo/bendamustine","J9036","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","32.65",,,,,,,"fee schedule","32.65","69.23",
"Inj. belrapzo/bendamustine","J9036","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","32.65",,,,,,,"fee schedule","32.65","69.23",
"Inj. belrapzo/bendamustine","J9036","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","32.65",,,,,,,"fee schedule","32.65","69.23",
"Inj. belrapzo/bendamustine","J9036","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","69.23",,,,,,,"fee schedule","32.65","69.23",
"Injection, blinatumomab","J9039","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","362.02",,,,,,,"fee schedule","350.23","384.05",
"Injection, blinatumomab","J9039","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","365.64",,,,,,,"fee schedule","350.23","384.05",
"Injection, blinatumomab","J9039","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","350.23",,,,,,,"fee schedule","350.23","384.05",
"Injection, blinatumomab","J9039","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","350.23",,,,,,,"fee schedule","350.23","384.05",
"Injection, blinatumomab","J9039","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","350.23",,,,,,,"fee schedule","350.23","384.05",
"Injection, blinatumomab","J9039","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","384.05",,,,,,,"fee schedule","350.23","384.05",
"Bleomycin sulfate injection","J9040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","49.58",,,,,,,"fee schedule","49.58","86.36",
"Bleomycin sulfate injection","J9040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","49.58",,,,,,,"fee schedule","49.58","86.36",
"Bleomycin sulfate injection","J9040","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","49.58",,,,,,,"fee schedule","49.58","86.36",
"Bleomycin sulfate injection","J9040","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","86.36",,,,,,,"fee schedule","49.58","86.36",
"Bortezomib injection","J9041","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.75",,,,,,,"fee schedule","5.75","152.74",
"Bortezomib injection","J9041","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.75",,,,,,,"fee schedule","5.75","152.74",
"Bortezomib injection","J9041","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.75",,,,,,,"fee schedule","5.75","152.74",
"Bortezomib injection","J9041","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","152.74",,,,,,,"fee schedule","5.75","152.74",
"Brentuximab vedotin inj","J9042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","563.65",,,,,,,"fee schedule","558.06","572.65",
"Brentuximab vedotin inj","J9042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","558.06",,,,,,,"fee schedule","558.06","572.65",
"Brentuximab vedotin inj","J9042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","572.54",,,,,,,"fee schedule","558.06","572.65",
"Brentuximab vedotin inj","J9042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","572.54",,,,,,,"fee schedule","558.06","572.65",
"Brentuximab vedotin inj","J9042","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","572.54",,,,,,,"fee schedule","558.06","572.65",
"Brentuximab vedotin inj","J9042","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","572.65",,,,,,,"fee schedule","558.06","572.65",
"Cabazitaxel injection","J9043","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","509.92",,,,,,,"fee schedule","509.92","599.21",
"Cabazitaxel injection","J9043","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","509.92",,,,,,,"fee schedule","509.92","599.21",
"Cabazitaxel injection","J9043","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","509.92",,,,,,,"fee schedule","509.92","599.21",
"Cabazitaxel injection","J9043","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","599.21",,,,,,,"fee schedule","509.92","599.21",
"Carboplatin injection","J9045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.74",,,,,,,"fee schedule","6.74","9.45",
"Carboplatin injection","J9045","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","9.45",,,,,,,"fee schedule","6.74","9.45",
"Carboplatin injection","J9045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.74",,,,,,,"fee schedule","6.74","9.45",
"Carboplatin injection","J9045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.74",,,,,,,"fee schedule","6.74","9.45",
"Injection, carfilzomib, 1 mg","J9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","119.25",,,,,,,"fee schedule","119.25","127.41",
"Injection, carfilzomib, 1 mg","J9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","119.25",,,,,,,"fee schedule","119.25","127.41",
"Injection, carfilzomib, 1 mg","J9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","119.25",,,,,,,"fee schedule","119.25","127.41",
"Injection, carfilzomib, 1 mg","J9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","127.41",,,,,,,"fee schedule","119.25","127.41",
"Inj, bortezomib, hospira","J9049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.3",,,,,,,"fee schedule","3.3","3.3",
"Inj, bortezomib, hospira","J9049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.3",,,,,,,"fee schedule","3.3","3.3",
"Inj, bortezomib, hospira","J9049","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.3",,,,,,,"fee schedule","3.3","3.3",
"Carmustine injection","J9050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","334.87",,,,,,,"fee schedule","334.87","6535.58",
"Carmustine injection","J9050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","334.87",,,,,,,"fee schedule","334.87","6535.58",
"Carmustine injection","J9050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","334.87",,,,,,,"fee schedule","334.87","6535.58",
"Carmustine injection","J9050","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6535.58",,,,,,,"fee schedule","334.87","6535.58",
"Cetuximab injection","J9055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","202.71",,,,,,,"fee schedule","178.31","213.42",
"Cetuximab injection","J9055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","200.71",,,,,,,"fee schedule","178.31","213.42",
"Cetuximab injection","J9055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","178.31",,,,,,,"fee schedule","178.31","213.42",
"Cetuximab injection","J9055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","178.31",,,,,,,"fee schedule","178.31","213.42",
"Cetuximab injection","J9055","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","178.31",,,,,,,"fee schedule","178.31","213.42",
"Cetuximab injection","J9055","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","213.42",,,,,,,"fee schedule","178.31","213.42",
"Inj, bendamustine, 1 mg","J9056","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","62.66",,,,,,,"fee schedule","62.66","62.66",
"Inj, bendamustine, 1 mg","J9056","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","62.66",,,,,,,"fee schedule","62.66","62.66",
"Inj, bendamustine, 1 mg","J9056","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","62.66",,,,,,,"fee schedule","62.66","62.66",
"Inj., copanlisib, 1 mg","J9057","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","268.59",,,,,,,"fee schedule","268.59","268.59",
"Cisplatin 10 mg injection","J9060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.58",,,,,,,"fee schedule","6.47","6.58",
"Cisplatin 10 mg injection","J9060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.58",,,,,,,"fee schedule","6.47","6.58",
"Cisplatin 10 mg injection","J9060","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.58",,,,,,,"fee schedule","6.47","6.58",
"Cisplatin 10 mg injection","J9060","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.47",,,,,,,"fee schedule","6.47","6.58",
"Inj, amivantamab-vmjw","J9061","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","49.47",,,,,,,"fee schedule","49.47","49.47",
"Inj, amivantamab-vmjw","J9061","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","49.47",,,,,,,"fee schedule","49.47","49.47",
"Inj, amivantamab-vmjw","J9061","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","49.47",,,,,,,"fee schedule","49.47","49.47",
"Inj, elahere, 1 mg","J9063","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","156.57",,,,,,,"fee schedule","156.57","156.57",
"Inj, elahere, 1 mg","J9063","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","156.57",,,,,,,"fee schedule","156.57","156.57",
"Inj, elahere, 1 mg","J9063","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","156.57",,,,,,,"fee schedule","156.57","156.57",
"Inj cladribine per 1 mg","J9065","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","23.46",,,,,,,"fee schedule","23.46","63.19",
"Inj cladribine per 1 mg","J9065","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","23.46",,,,,,,"fee schedule","23.46","63.19",
"Inj cladribine per 1 mg","J9065","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","23.46",,,,,,,"fee schedule","23.46","63.19",
"Inj cladribine per 1 mg","J9065","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","63.19",,,,,,,"fee schedule","23.46","63.19",
"Inj cyclophosphamd auromedic","J9071","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2",,,,,,,"fee schedule","2","2",
"Inj cyclophosphamd auromedic","J9071","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2",,,,,,,"fee schedule","2","2",
"Inj cyclophosphamd auromedic","J9071","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2",,,,,,,"fee schedule","2","2",
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20.82",,,,,,,"fee schedule","20.82","20.82",
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20.82",,,,,,,"fee schedule","20.82","20.82",
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","20.82",,,,,,,"fee schedule","20.82","20.82",
"Inj cyclophosphamd (ingenus)","J9073","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4.05",,,,,,,"fee schedule","4.05","4.05",
"Inj cyclophosphamd (ingenus)","J9073","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4.05",,,,,,,"fee schedule","4.05","4.05",
"Inj cyclophosphamd (ingenus)","J9073","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4.05",,,,,,,"fee schedule","4.05","4.05",
"Inj, cyclophosphamd, sandoz","J9074","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.99",,,,,,,"fee schedule","9.99","9.99",
"Inj, cyclophosphamd, sandoz","J9074","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.99",,,,,,,"fee schedule","9.99","9.99",
"Inj, cyclophosphamd, sandoz","J9074","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.99",,,,,,,"fee schedule","9.99","9.99",
"Inj, cyclophosphamide, nos","J9075","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.84",,,,,,,"fee schedule","1.84","12.75",
"Inj, cyclophosphamide, nos","J9075","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.84",,,,,,,"fee schedule","1.84","12.75",
"Inj, cyclophosphamide, nos","J9075","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.84",,,,,,,"fee schedule","1.84","12.75",
"Inj, cyclophosphamide, nos","J9075","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.75",,,,,,,"fee schedule","1.84","12.75",
"Cytarabine liposome inj","J9098","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1671.18",,,,,,,"fee schedule","1671.18","1671.18",
"Cytarabine hcl 100 mg inj","J9100","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.87",,,,,,,"fee schedule","1.87","2.24",
"Cytarabine hcl 100 mg inj","J9100","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.87",,,,,,,"fee schedule","1.87","2.24",
"Cytarabine hcl 100 mg inj","J9100","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.24",,,,,,,"fee schedule","1.87","2.24",
"Cytarabine hcl 100 mg inj","J9100","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.87",,,,,,,"fee schedule","1.87","2.24",
"Inj. calaspargase pegol-mknl","J9118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","176.01",,,,,,,"fee schedule","176.01","259.74",
"Inj. calaspargase pegol-mknl","J9118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","176.01",,,,,,,"fee schedule","176.01","259.74",
"Inj. calaspargase pegol-mknl","J9118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","176.01",,,,,,,"fee schedule","176.01","259.74",
"Inj. calaspargase pegol-mknl","J9118","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","259.74",,,,,,,"fee schedule","176.01","259.74",
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","66.52",,,,,,,"fee schedule","66.52","92.97",
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","66.52",,,,,,,"fee schedule","66.52","92.97",
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","66.52",,,,,,,"fee schedule","66.52","92.97",
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","92.97",,,,,,,"fee schedule","66.52","92.97",
"Dactinomycin injection","J9120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","664.23",,,,,,,"fee schedule","664.23","3306.08",
"Dactinomycin injection","J9120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","664.23",,,,,,,"fee schedule","664.23","3306.08",
"Dactinomycin injection","J9120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","664.23",,,,,,,"fee schedule","664.23","3306.08",
"Dactinomycin injection","J9120","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3306.08",,,,,,,"fee schedule","664.23","3306.08",
"Dacarbazine 100 mg inj","J9130","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.36",,,,,,,"fee schedule","10.36","14.36",
"Dacarbazine 100 mg inj","J9130","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.36",,,,,,,"fee schedule","10.36","14.36",
"Dacarbazine 100 mg inj","J9130","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.36",,,,,,,"fee schedule","10.36","14.36",
"Dacarbazine 100 mg inj","J9130","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14.36",,,,,,,"fee schedule","10.36","14.36",
"Daratumumab, hyaluronidase","J9144","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","121.88",,,,,,,"fee schedule","106.36","121.88",
"Daratumumab, hyaluronidase","J9144","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","121.88",,,,,,,"fee schedule","106.36","121.88",
"Daratumumab, hyaluronidase","J9144","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","121.88",,,,,,,"fee schedule","106.36","121.88",
"Daratumumab, hyaluronidase","J9144","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","106.36",,,,,,,"fee schedule","106.36","121.88",
"Injection, daratumumab 10 mg","J9145","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","173.46",,,,,,,"fee schedule","155.54","183.59",
"Injection, daratumumab 10 mg","J9145","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","155.54",,,,,,,"fee schedule","155.54","183.59",
"Injection, daratumumab 10 mg","J9145","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","171.74",,,,,,,"fee schedule","155.54","183.59",
"Injection, daratumumab 10 mg","J9145","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","155.54",,,,,,,"fee schedule","155.54","183.59",
"Injection, daratumumab 10 mg","J9145","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","155.54",,,,,,,"fee schedule","155.54","183.59",
"Injection, daratumumab 10 mg","J9145","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","183.59",,,,,,,"fee schedule","155.54","183.59",
"Daunorubicin injection","J9150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","60.71",,,,,,,"fee schedule","60.71","157.11",
"Daunorubicin injection","J9150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","60.71",,,,,,,"fee schedule","60.71","157.11",
"Daunorubicin injection","J9150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","60.71",,,,,,,"fee schedule","60.71","157.11",
"Daunorubicin injection","J9150","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","157.11",,,,,,,"fee schedule","60.71","157.11",
"Daunorubicin citrate inj","J9151","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","195.75",,,,,,,"fee schedule","195.75","195.75",
"Inj daunorubicin, cytarabine","J9153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","572.75",,,,,,,"fee schedule","572.75","671.57",
"Inj daunorubicin, cytarabine","J9153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","572.75",,,,,,,"fee schedule","572.75","671.57",
"Inj daunorubicin, cytarabine","J9153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","572.75",,,,,,,"fee schedule","572.75","671.57",
"Inj daunorubicin, cytarabine","J9153","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","671.57",,,,,,,"fee schedule","572.75","671.57",
"Degarelix injection","J9155","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","10.02",,,,,,,"fee schedule","10.02","13.13",
"Degarelix injection","J9155","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","10.02",,,,,,,"fee schedule","10.02","13.13",
"Degarelix injection","J9155","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","10.02",,,,,,,"fee schedule","10.02","13.13",
"Degarelix injection","J9155","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13.13",,,,,,,"fee schedule","10.02","13.13",
"Docetaxel injection","J9171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.41",,,,,,,"fee schedule","1.41","3.52",
"Docetaxel injection","J9171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.41",,,,,,,"fee schedule","1.41","3.52",
"Docetaxel injection","J9171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.41",,,,,,,"fee schedule","1.41","3.52",
"Docetaxel injection","J9171","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.52",,,,,,,"fee schedule","1.41","3.52",
"Docetaxel (ingenus), 1 mg","J9172","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","118.73",,,,,,,"fee schedule","118.73","118.73",
"Docetaxel (ingenus), 1 mg","J9172","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","118.73",,,,,,,"fee schedule","118.73","118.73",
"Docetaxel (ingenus), 1 mg","J9172","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","118.73",,,,,,,"fee schedule","118.73","118.73",
"Inj., durvalumab, 10 mg","J9173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","238.53",,,,,,,"fee schedule","192.9","255.93",
"Inj., durvalumab, 10 mg","J9173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","192.9",,,,,,,"fee schedule","192.9","255.93",
"Inj., durvalumab, 10 mg","J9173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","192.9",,,,,,,"fee schedule","192.9","255.93",
"Inj., durvalumab, 10 mg","J9173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","236.17",,,,,,,"fee schedule","192.9","255.93",
"Inj., durvalumab, 10 mg","J9173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","192.9",,,,,,,"fee schedule","192.9","255.93",
"Inj., durvalumab, 10 mg","J9173","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","255.93",,,,,,,"fee schedule","192.9","255.93",
"Elliotts b solution per ml","J9175","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","31.06",,,,,,,"fee schedule","31.06","31.06",
"Injection, elotuzumab, 1mg","J9176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","20.67",,,,,,,"fee schedule","17.78","22.29",
"Injection, elotuzumab, 1mg","J9176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17.78",,,,,,,"fee schedule","17.78","22.29",
"Injection, elotuzumab, 1mg","J9176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","20.46",,,,,,,"fee schedule","17.78","22.29",
"Injection, elotuzumab, 1mg","J9176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17.78",,,,,,,"fee schedule","17.78","22.29",
"Injection, elotuzumab, 1mg","J9176","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17.78",,,,,,,"fee schedule","17.78","22.29",
"Injection, elotuzumab, 1mg","J9176","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","22.29",,,,,,,"fee schedule","17.78","22.29",
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","84.28",,,,,,,"fee schedule","84.28","84.28",
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","84.28",,,,,,,"fee schedule","84.28","84.28",
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","84.28",,,,,,,"fee schedule","84.28","84.28",
"Inj, epirubicin hcl, 2 mg","J9178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.72",,,,,,,"fee schedule","3.72","4.1",
"Inj, epirubicin hcl, 2 mg","J9178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.72",,,,,,,"fee schedule","3.72","4.1",
"Inj, epirubicin hcl, 2 mg","J9178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.72",,,,,,,"fee schedule","3.72","4.1",
"Inj, epirubicin hcl, 2 mg","J9178","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.1",,,,,,,"fee schedule","3.72","4.1",
"Eribulin mesylate injection","J9179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","273.12",,,,,,,"fee schedule","273.12","395.52",
"Eribulin mesylate injection","J9179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","273.12",,,,,,,"fee schedule","273.12","395.52",
"Eribulin mesylate injection","J9179","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","273.12",,,,,,,"fee schedule","273.12","395.52",
"Eribulin mesylate injection","J9179","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","395.52",,,,,,,"fee schedule","273.12","395.52",
"Etoposide injection","J9181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.45",,,,,,,"fee schedule","2.08","2.45",
"Etoposide injection","J9181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.45",,,,,,,"fee schedule","2.08","2.45",
"Etoposide injection","J9181","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.08",,,,,,,"fee schedule","2.08","2.45",
"Etoposide injection","J9181","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.45",,,,,,,"fee schedule","2.08","2.45",
"Fludarabine phosphate inj","J9185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","136.92",,,,,,,"fee schedule","136.92","151.69",
"Fludarabine phosphate inj","J9185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","136.92",,,,,,,"fee schedule","136.92","151.69",
"Fludarabine phosphate inj","J9185","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","136.92",,,,,,,"fee schedule","136.92","151.69",
"Fludarabine phosphate inj","J9185","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","151.69",,,,,,,"fee schedule","136.92","151.69",
"Fluorouracil injection","J9190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.07",,,,,,,"fee schedule","5.07","5.94",
"Fluorouracil injection","J9190","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5.94",,,,,,,"fee schedule","5.07","5.94",
"Fluorouracil injection","J9190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.07",,,,,,,"fee schedule","5.07","5.94",
"Fluorouracil injection","J9190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.07",,,,,,,"fee schedule","5.07","5.94",
"Inj gemcitabine hcl (accord)","J9196","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19.9",,,,,,,"fee schedule","19.9","19.9",
"Inj gemcitabine hcl (accord)","J9196","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19.9",,,,,,,"fee schedule","19.9","19.9",
"Inj gemcitabine hcl (accord)","J9196","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19.9",,,,,,,"fee schedule","19.9","19.9",
"Inj. infugem, 100 mg","J9198","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","309.21",,,,,,,"fee schedule","309.21","309.21",
"Floxuridine injection","J9200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9173.17",,,,,,,"fee schedule","262.11","9173.17",
"Floxuridine injection","J9200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9173.17",,,,,,,"fee schedule","262.11","9173.17",
"Floxuridine injection","J9200","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9173.17",,,,,,,"fee schedule","262.11","9173.17",
"Floxuridine injection","J9200","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","262.11",,,,,,,"fee schedule","262.11","9173.17",
"Gemcitabine hcl injection","J9201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6.84",,,,,,,"fee schedule","6.84","13.09",
"Gemcitabine hcl injection","J9201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6.84",,,,,,,"fee schedule","6.84","13.09",
"Gemcitabine hcl injection","J9201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6.84",,,,,,,"fee schedule","6.84","13.09",
"Gemcitabine hcl injection","J9201","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13.09",,,,,,,"fee schedule","6.84","13.09",
"Goserelin acetate implant","J9202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","1536.36",,,,,,,"fee schedule","1536.36","1696.24",
"Goserelin acetate implant","J9202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1621.82",,,,,,,"fee schedule","1536.36","1696.24",
"Goserelin acetate implant","J9202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1621.82",,,,,,,"fee schedule","1536.36","1696.24",
"Goserelin acetate implant","J9202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","1551.73",,,,,,,"fee schedule","1536.36","1696.24",
"Goserelin acetate implant","J9202","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1621.82",,,,,,,"fee schedule","1536.36","1696.24",
"Goserelin acetate implant","J9202","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1696.24",,,,,,,"fee schedule","1536.36","1696.24",
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","536.17",,,,,,,"fee schedule","536.17","676.45",
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","536.17",,,,,,,"fee schedule","536.17","676.45",
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","536.17",,,,,,,"fee schedule","536.17","676.45",
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","676.45",,,,,,,"fee schedule","536.17","676.45",
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","560.34",,,,,,,"fee schedule","560.34","681.02",
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","560.34",,,,,,,"fee schedule","560.34","681.02",
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","560.34",,,,,,,"fee schedule","560.34","681.02",
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","681.02",,,,,,,"fee schedule","560.34","681.02",
"Inj irinotecan liposome 1 mg","J9205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","150.14",,,,,,,"fee schedule","150.14","168.76",
"Inj irinotecan liposome 1 mg","J9205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","150.14",,,,,,,"fee schedule","150.14","168.76",
"Inj irinotecan liposome 1 mg","J9205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","150.14",,,,,,,"fee schedule","150.14","168.76",
"Inj irinotecan liposome 1 mg","J9205","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","168.76",,,,,,,"fee schedule","150.14","168.76",
"Irinotecan injection","J9206","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.77",,,,,,,"fee schedule","3.77","8.44",
"Irinotecan injection","J9206","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.77",,,,,,,"fee schedule","3.77","8.44",
"Irinotecan injection","J9206","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.77",,,,,,,"fee schedule","3.77","8.44",
"Irinotecan injection","J9206","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8.44",,,,,,,"fee schedule","3.77","8.44",
"Ixabepilone injection","J9207","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","313.28",,,,,,,"fee schedule","313.28","336.9",
"Ixabepilone injection","J9207","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","313.28",,,,,,,"fee schedule","313.28","336.9",
"Ixabepilone injection","J9207","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","313.28",,,,,,,"fee schedule","313.28","336.9",
"Ixabepilone injection","J9207","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","336.9",,,,,,,"fee schedule","313.28","336.9",
"Ifosfamide injection","J9208","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","56.62",,,,,,,"fee schedule","56.62","89",
"Ifosfamide injection","J9208","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","56.62",,,,,,,"fee schedule","56.62","89",
"Ifosfamide injection","J9208","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","56.62",,,,,,,"fee schedule","56.62","89",
"Ifosfamide injection","J9208","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","89",,,,,,,"fee schedule","56.62","89",
"Mesna injection","J9209","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.13",,,,,,,"fee schedule","2.29","3.13",
"Mesna injection","J9209","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.13",,,,,,,"fee schedule","2.29","3.13",
"Mesna injection","J9209","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.13",,,,,,,"fee schedule","2.29","3.13",
"Mesna injection","J9209","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.29",,,,,,,"fee schedule","2.29","3.13",
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","877.46",,,,,,,"fee schedule","877.46","1808.33",
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","877.46",,,,,,,"fee schedule","877.46","1808.33",
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","877.46",,,,,,,"fee schedule","877.46","1808.33",
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1808.33",,,,,,,"fee schedule","877.46","1808.33",
"Idarubicin hcl injection","J9211","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","100.06",,,,,,,"fee schedule","100.06","112.24",
"Idarubicin hcl injection","J9211","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","100.06",,,,,,,"fee schedule","100.06","112.24",
"Idarubicin hcl injection","J9211","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","100.06",,,,,,,"fee schedule","100.06","112.24",
"Idarubicin hcl injection","J9211","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","112.24",,,,,,,"fee schedule","100.06","112.24",
"Interferon alfacon-1 inj","J9212","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","23.26",,,,,,,"fee schedule","23.26","23.26",
"Interferon alfa-2a inj","J9213","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1380.68",,,,,,,"fee schedule","1380.68","1380.68",
"Interferon alfa-2b inj","J9214","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","113.75",,,,,,,"fee schedule","113.75","113.75",
"Interferon alfa-n3 inj","J9215","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","122.54",,,,,,,"fee schedule","122.54","122.54",
"Interferon gamma 1-b inj","J9216","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","27944.29",,,,,,,"fee schedule","27944.29","27944.29",
"Leuprolide acetate suspnsion","J9217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","701.66",,,,,,,"fee schedule","396.26","798",
"Leuprolide acetate suspnsion","J9217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","396.26",,,,,,,"fee schedule","396.26","798",
"Leuprolide acetate suspnsion","J9217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","708.68",,,,,,,"fee schedule","396.26","798",
"Leuprolide acetate suspnsion","J9217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","396.26",,,,,,,"fee schedule","396.26","798",
"Leuprolide acetate suspnsion","J9217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","396.26",,,,,,,"fee schedule","396.26","798",
"Leuprolide acetate suspnsion","J9217","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","798",,,,,,,"fee schedule","396.26","798",
"Leuprolide acetate injeciton","J9218","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","42",,,,,,,"fee schedule","42","42",
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","471.58",,,,,,,"fee schedule","471.58","471.58",
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","471.58",,,,,,,"fee schedule","471.58","471.58",
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","471.58",,,,,,,"fee schedule","471.58","471.58",
"Vantas implant","J9225","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","14197.07",,,,,,,"fee schedule","14056.51","14599.28",
"Vantas implant","J9225","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","14056.51",,,,,,,"fee schedule","14056.51","14599.28",
"Vantas implant","J9225","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","14599.28",,,,,,,"fee schedule","14056.51","14599.28",
"Supprelin LA implant","J9226","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","124182.95",,,,,,,"fee schedule","103987.69","129708.04",
"Supprelin LA implant","J9226","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","122953.4",,,,,,,"fee schedule","103987.69","129708.04",
"Supprelin LA implant","J9226","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","103987.69",,,,,,,"fee schedule","103987.69","129708.04",
"Supprelin LA implant","J9226","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","103987.69",,,,,,,"fee schedule","103987.69","129708.04",
"Supprelin LA implant","J9226","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","103987.69",,,,,,,"fee schedule","103987.69","129708.04",
"Supprelin LA implant","J9226","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","129708.04",,,,,,,"fee schedule","103987.69","129708.04",
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","181.37",,,,,,,"fee schedule","181.37","181.37",
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","181.37",,,,,,,"fee schedule","181.37","181.37",
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","181.37",,,,,,,"fee schedule","181.37","181.37",
"Ipilimumab injection","J9228","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","486.69",,,,,,,"fee schedule","414.49","526.3",
"Ipilimumab injection","J9228","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","481.88",,,,,,,"fee schedule","414.49","526.3",
"Ipilimumab injection","J9228","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","414.49",,,,,,,"fee schedule","414.49","526.3",
"Ipilimumab injection","J9228","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","414.49",,,,,,,"fee schedule","414.49","526.3",
"Ipilimumab injection","J9228","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","414.49",,,,,,,"fee schedule","414.49","526.3",
"Ipilimumab injection","J9228","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","526.3",,,,,,,"fee schedule","414.49","526.3",
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6113.7",,,,,,,"fee schedule","6113.7","7708.24",
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6113.7",,,,,,,"fee schedule","6113.7","7708.24",
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6113.7",,,,,,,"fee schedule","6113.7","7708.24",
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7708.24",,,,,,,"fee schedule","6113.7","7708.24",
"Mechlorethamine hcl inj","J9230","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1113.02",,,,,,,"fee schedule","1113.02","1113.02",
"Inj melphalan hydrochl 50 MG","J9245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","361.33",,,,,,,"fee schedule","361.33","1767.65",
"Inj melphalan hydrochl 50 MG","J9245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","361.33",,,,,,,"fee schedule","361.33","1767.65",
"Inj melphalan hydrochl 50 MG","J9245","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","361.33",,,,,,,"fee schedule","361.33","1767.65",
"Inj melphalan hydrochl 50 MG","J9245","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1767.65",,,,,,,"fee schedule","361.33","1767.65",
"Inj., evomela, 1 mg","J9246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","42.55",,,,,,,"fee schedule","42.55","42.55",
"Inj., evomela, 1 mg","J9246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","42.55",,,,,,,"fee schedule","42.55","42.55",
"Inj., evomela, 1 mg","J9246","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","42.55",,,,,,,"fee schedule","42.55","42.55",
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1779.74",,,,,,,"fee schedule","1779.74","1779.74",
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1779.74",,,,,,,"fee schedule","1779.74","1779.74",
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1779.74",,,,,,,"fee schedule","1779.74","1779.74",
"Methotrexate sodium inj","J9260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.94",,,,,,,"fee schedule","5.94","7.97",
"Methotrexate sodium inj","J9260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.94",,,,,,,"fee schedule","5.94","7.97",
"Methotrexate sodium inj","J9260","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.94",,,,,,,"fee schedule","5.94","7.97",
"Methotrexate sodium inj","J9260","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.97",,,,,,,"fee schedule","5.94","7.97",
"Nelarabine injection","J9261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","145.32",,,,,,,"fee schedule","145.32","517.12",
"Nelarabine injection","J9261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","145.32",,,,,,,"fee schedule","145.32","517.12",
"Nelarabine injection","J9261","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","145.32",,,,,,,"fee schedule","145.32","517.12",
"Nelarabine injection","J9261","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","517.12",,,,,,,"fee schedule","145.32","517.12",
"Inj, omacetaxine mep, 0.01mg","J9262","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.54",,,,,,,"fee schedule","10.54","10.54",
"Oxaliplatin","J9263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.11",,,,,,,"fee schedule","0.11","0.47",
"Oxaliplatin","J9263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.11",,,,,,,"fee schedule","0.11","0.47",
"Oxaliplatin","J9263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.11",,,,,,,"fee schedule","0.11","0.47",
"Oxaliplatin","J9263","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.47",,,,,,,"fee schedule","0.11","0.47",
"Paclitaxel protein bound","J9264","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","30.05",,,,,,,"fee schedule","30.05","43.14",
"Paclitaxel protein bound","J9264","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","30.05",,,,,,,"fee schedule","30.05","43.14",
"Paclitaxel protein bound","J9264","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","30.05",,,,,,,"fee schedule","30.05","43.14",
"Paclitaxel protein bound","J9264","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","43.14",,,,,,,"fee schedule","30.05","43.14",
"Pegaspargase injection","J9266","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","61037.3",,,,,,,"fee schedule","60432.98","62262.23",
"Pegaspargase injection","J9266","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","62262.23",,,,,,,"fee schedule","60432.98","62262.23",
"Pegaspargase injection","J9266","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","62262.23",,,,,,,"fee schedule","60432.98","62262.23",
"Pegaspargase injection","J9266","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","60432.98",,,,,,,"fee schedule","60432.98","62262.23",
"Pegaspargase injection","J9266","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","62262.23",,,,,,,"fee schedule","60432.98","62262.23",
"Pegaspargase injection","J9266","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","61062.67",,,,,,,"fee schedule","60432.98","62262.23",
"Paclitaxel injection","J9267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.29",,,,,,,"fee schedule","0.29","0.42",
"Paclitaxel injection","J9267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.29",,,,,,,"fee schedule","0.29","0.42",
"Paclitaxel injection","J9267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.29",,,,,,,"fee schedule","0.29","0.42",
"Paclitaxel injection","J9267","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.42",,,,,,,"fee schedule","0.29","0.42",
"Pentostatin injection","J9268","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6148.89",,,,,,,"fee schedule","6148.89","6966.02",
"Pentostatin injection","J9268","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6148.89",,,,,,,"fee schedule","6148.89","6966.02",
"Pentostatin injection","J9268","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6148.89",,,,,,,"fee schedule","6148.89","6966.02",
"Pentostatin injection","J9268","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6966.02",,,,,,,"fee schedule","6148.89","6966.02",
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","778.62",,,,,,,"fee schedule","778.62","917.47",
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","778.62",,,,,,,"fee schedule","778.62","917.47",
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","778.62",,,,,,,"fee schedule","778.62","917.47",
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","917.47",,,,,,,"fee schedule","778.62","917.47",
"Inj pembrolizumab","J9271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","155.22",,,,,,,"fee schedule","136.5","169.59",
"Inj pembrolizumab","J9271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","156.78",,,,,,,"fee schedule","136.5","169.59",
"Inj pembrolizumab","J9271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","136.5",,,,,,,"fee schedule","136.5","169.59",
"Inj pembrolizumab","J9271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","136.5",,,,,,,"fee schedule","136.5","169.59",
"Inj pembrolizumab","J9271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","136.5",,,,,,,"fee schedule","136.5","169.59",
"Inj pembrolizumab","J9271","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","169.59",,,,,,,"fee schedule","136.5","169.59",
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","552.31",,,,,,,"fee schedule","482","552.31",
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","552.31",,,,,,,"fee schedule","482","552.31",
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","552.31",,,,,,,"fee schedule","482","552.31",
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","482",,,,,,,"fee schedule","482","552.31",
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","433.9",,,,,,,"fee schedule","433.9","433.9",
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","433.9",,,,,,,"fee schedule","433.9","433.9",
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","433.9",,,,,,,"fee schedule","433.9","433.9",
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","493.94",,,,,,,"fee schedule","493.94","493.94",
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","493.94",,,,,,,"fee schedule","493.94","493.94",
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","493.94",,,,,,,"fee schedule","493.94","493.94",
"Mitomycin injection","J9280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","58.88",,,,,,,"fee schedule","58.88","219.11",
"Mitomycin injection","J9280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","58.88",,,,,,,"fee schedule","58.88","219.11",
"Mitomycin injection","J9280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","58.88",,,,,,,"fee schedule","58.88","219.11",
"Mitomycin injection","J9280","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","219.11",,,,,,,"fee schedule","58.88","219.11",
"Mitomycin instillation","J9281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","719.89",,,,,,,"fee schedule","719.89","719.89",
"Mitomycin instillation","J9281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","719.89",,,,,,,"fee schedule","719.89","719.89",
"Mitomycin instillation","J9281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","719.89",,,,,,,"fee schedule","719.89","719.89",
"Inj, olaratumab, 10 mg","J9285","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","176.54",,,,,,,"fee schedule","176.54","176.54",
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6377.44",,,,,,,"fee schedule","6377.44","6377.44",
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6377.44",,,,,,,"fee schedule","6377.44","6377.44",
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6377.44",,,,,,,"fee schedule","6377.44","6377.44",
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","63.69",,,,,,,"fee schedule","63.69","99.75",
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","63.69",,,,,,,"fee schedule","63.69","99.75",
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","63.69",,,,,,,"fee schedule","63.69","99.75",
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","99.75",,,,,,,"fee schedule","63.69","99.75",
"Inj pemetrexed, hospira 10mg","J9294","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.88",,,,,,,"fee schedule","8.88","8.88",
"Inj pemetrexed, hospira 10mg","J9294","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.88",,,,,,,"fee schedule","8.88","8.88",
"Inj pemetrexed, hospira 10mg","J9294","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.88",,,,,,,"fee schedule","8.88","8.88",
"Injection, necitumumab, 1 mg","J9295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13.18",,,,,,,"fee schedule","13.18","19.41",
"Injection, necitumumab, 1 mg","J9295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13.18",,,,,,,"fee schedule","13.18","19.41",
"Injection, necitumumab, 1 mg","J9295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13.18",,,,,,,"fee schedule","13.18","19.41",
"Injection, necitumumab, 1 mg","J9295","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","19.41",,,,,,,"fee schedule","13.18","19.41",
"Inj pemetrexed (accord) 10mg","J9296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","22.39",,,,,,,"fee schedule","22.39","22.39",
"Inj pemetrexed (accord) 10mg","J9296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","22.39",,,,,,,"fee schedule","22.39","22.39",
"Inj pemetrexed (accord) 10mg","J9296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","22.39",,,,,,,"fee schedule","22.39","22.39",
"Inj pemetrexed (sandoz) 10mg","J9297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4",,,,,,,"fee schedule","4","4",
"Inj pemetrexed (sandoz) 10mg","J9297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4",,,,,,,"fee schedule","4","4",
"Inj pemetrexed (sandoz) 10mg","J9297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4",,,,,,,"fee schedule","4","4",
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","446.38",,,,,,,"fee schedule","446.38","446.38",
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","446.38",,,,,,,"fee schedule","446.38","446.38",
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","446.38",,,,,,,"fee schedule","446.38","446.38",
"Injection, nivolumab","J9299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","88.35",,,,,,,"fee schedule","74.41","95.48",
"Injection, nivolumab","J9299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","74.41",,,,,,,"fee schedule","74.41","95.48",
"Injection, nivolumab","J9299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","87.49",,,,,,,"fee schedule","74.41","95.48",
"Injection, nivolumab","J9299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","74.41",,,,,,,"fee schedule","74.41","95.48",
"Injection, nivolumab","J9299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","74.41",,,,,,,"fee schedule","74.41","95.48",
"Injection, nivolumab","J9299","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","95.48",,,,,,,"fee schedule","74.41","95.48",
"Obinutuzumab inj","J9301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","194.75",,,,,,,"fee schedule","172.99","215.21",
"Obinutuzumab inj","J9301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","196.7",,,,,,,"fee schedule","172.99","215.21",
"Obinutuzumab inj","J9301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","172.99",,,,,,,"fee schedule","172.99","215.21",
"Obinutuzumab inj","J9301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","172.99",,,,,,,"fee schedule","172.99","215.21",
"Obinutuzumab inj","J9301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","172.99",,,,,,,"fee schedule","172.99","215.21",
"Obinutuzumab inj","J9301","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","215.21",,,,,,,"fee schedule","172.99","215.21",
"Ofatumumab injection","J9302","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","203.49",,,,,,,"fee schedule","203.49","203.49",
"Panitumumab injection","J9303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","384.36",,,,,,,"fee schedule","379.32","402.02",
"Panitumumab injection","J9303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","380.55",,,,,,,"fee schedule","379.32","402.02",
"Panitumumab injection","J9303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","379.32",,,,,,,"fee schedule","379.32","402.02",
"Panitumumab injection","J9303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","379.32",,,,,,,"fee schedule","379.32","402.02",
"Panitumumab injection","J9303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","379.32",,,,,,,"fee schedule","379.32","402.02",
"Panitumumab injection","J9303","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","402.02",,,,,,,"fee schedule","379.32","402.02",
"Inj. pemetrexed, 10 mg","J9304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","106.61",,,,,,,"fee schedule","106.61","106.61",
"Inj. pemetrexed, 10 mg","J9304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","106.61",,,,,,,"fee schedule","106.61","106.61",
"Inj. pemetrexed, 10 mg","J9304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","106.61",,,,,,,"fee schedule","106.61","106.61",
"Pemetrexed injection","J9305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8.67",,,,,,,"fee schedule","8.67","239.11",
"Pemetrexed injection","J9305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8.67",,,,,,,"fee schedule","8.67","239.11",
"Pemetrexed injection","J9305","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8.67",,,,,,,"fee schedule","8.67","239.11",
"Pemetrexed injection","J9305","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","239.11",,,,,,,"fee schedule","8.67","239.11",
"Injection, pertuzumab, 1 mg","J9306","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","40.2",,,,,,,"fee schedule","37.33","42.85",
"Injection, pertuzumab, 1 mg","J9306","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","39.79",,,,,,,"fee schedule","37.33","42.85",
"Injection, pertuzumab, 1 mg","J9306","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","37.33",,,,,,,"fee schedule","37.33","42.85",
"Injection, pertuzumab, 1 mg","J9306","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","37.33",,,,,,,"fee schedule","37.33","42.85",
"Injection, pertuzumab, 1 mg","J9306","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","37.33",,,,,,,"fee schedule","37.33","42.85",
"Injection, pertuzumab, 1 mg","J9306","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","42.85",,,,,,,"fee schedule","37.33","42.85",
"Pralatrexate injection","J9307","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","859.67",,,,,,,"fee schedule","859.67","1007.55",
"Pralatrexate injection","J9307","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","859.67",,,,,,,"fee schedule","859.67","1007.55",
"Pralatrexate injection","J9307","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","859.67",,,,,,,"fee schedule","859.67","1007.55",
"Pralatrexate injection","J9307","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1007.55",,,,,,,"fee schedule","859.67","1007.55",
"Injection, ramucirumab","J9308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","190.86",,,,,,,"fee schedule","168.75","201.82",
"Injection, ramucirumab","J9308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","188.97",,,,,,,"fee schedule","168.75","201.82",
"Injection, ramucirumab","J9308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","168.75",,,,,,,"fee schedule","168.75","201.82",
"Injection, ramucirumab","J9308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","168.75",,,,,,,"fee schedule","168.75","201.82",
"Injection, ramucirumab","J9308","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","168.75",,,,,,,"fee schedule","168.75","201.82",
"Injection, ramucirumab","J9308","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","201.82",,,,,,,"fee schedule","168.75","201.82",
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","305.27",,,,,,,"fee schedule","305.27","381.14",
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","305.27",,,,,,,"fee schedule","305.27","381.14",
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","305.27",,,,,,,"fee schedule","305.27","381.14",
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","381.14",,,,,,,"fee schedule","305.27","381.14",
"Inj rituximab, hyaluronidase","J9311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","123.3",,,,,,,"fee schedule","86.31","143.85",
"Inj rituximab, hyaluronidase","J9311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","124.53",,,,,,,"fee schedule","86.31","143.85",
"Inj rituximab, hyaluronidase","J9311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","86.31",,,,,,,"fee schedule","86.31","143.85",
"Inj rituximab, hyaluronidase","J9311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","86.31",,,,,,,"fee schedule","86.31","143.85",
"Inj rituximab, hyaluronidase","J9311","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","86.31",,,,,,,"fee schedule","86.31","143.85",
"Inj rituximab, hyaluronidase","J9311","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","143.85",,,,,,,"fee schedule","86.31","143.85",
"Inj., rituximab, 10 mg","J9312","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","282.52",,,,,,,"fee schedule","175.8","319.29",
"Inj., rituximab, 10 mg","J9312","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","279.72",,,,,,,"fee schedule","175.8","319.29",
"Inj., rituximab, 10 mg","J9312","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","175.8",,,,,,,"fee schedule","175.8","319.29",
"Inj., rituximab, 10 mg","J9312","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","175.8",,,,,,,"fee schedule","175.8","319.29",
"Inj., rituximab, 10 mg","J9312","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","175.8",,,,,,,"fee schedule","175.8","319.29",
"Inj., rituximab, 10 mg","J9312","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","319.29",,,,,,,"fee schedule","175.8","319.29",
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","74.9",,,,,,,"fee schedule","74.9","74.9",
"Inj pemetrexed (teva) 10mg","J9314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19.25",,,,,,,"fee schedule","19.25","19.25",
"Inj pemetrexed (teva) 10mg","J9314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19.25",,,,,,,"fee schedule","19.25","19.25",
"Inj pemetrexed (teva) 10mg","J9314","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19.25",,,,,,,"fee schedule","19.25","19.25",
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","144.88",,,,,,,"fee schedule","144.88","144.88",
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","144.88",,,,,,,"fee schedule","144.88","144.88",
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","144.88",,,,,,,"fee schedule","144.88","144.88",
"Sacituzumab govitecan-hziy","J9317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","82.34",,,,,,,"fee schedule","82.34","82.34",
"Sacituzumab govitecan-hziy","J9317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","82.34",,,,,,,"fee schedule","82.34","82.34",
"Sacituzumab govitecan-hziy","J9317","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","82.34",,,,,,,"fee schedule","82.34","82.34",
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","72.54",,,,,,,"fee schedule","72.54","94.62",
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","72.54",,,,,,,"fee schedule","72.54","94.62",
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","72.54",,,,,,,"fee schedule","72.54","94.62",
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","94.62",,,,,,,"fee schedule","72.54","94.62",
"Streptozocin injection","J9320","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1191.54",,,,,,,"fee schedule","1191.54","1191.54",
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","126.18",,,,,,,"fee schedule","126.18","126.18",
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","126.18",,,,,,,"fee schedule","126.18","126.18",
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","126.18",,,,,,,"fee schedule","126.18","126.18",
"Inj pemetrexed ditromethamin","J9323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","23.79",,,,,,,"fee schedule","23.79","23.79",
"Inj pemetrexed ditromethamin","J9323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","23.79",,,,,,,"fee schedule","23.79","23.79",
"Inj pemetrexed ditromethamin","J9323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","23.79",,,,,,,"fee schedule","23.79","23.79",
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","186.43",,,,,,,"fee schedule","186.43","186.43",
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","186.43",,,,,,,"fee schedule","186.43","186.43",
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","186.43",,,,,,,"fee schedule","186.43","186.43",
"Inj talimogene laherparepvec","J9325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","161.86",,,,,,,"fee schedule","161.86","174.7",
"Inj talimogene laherparepvec","J9325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","161.86",,,,,,,"fee schedule","161.86","174.7",
"Inj talimogene laherparepvec","J9325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","161.86",,,,,,,"fee schedule","161.86","174.7",
"Inj talimogene laherparepvec","J9325","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","174.7",,,,,,,"fee schedule","161.86","174.7",
"Temozolomide injection","J9328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","23.93",,,,,,,"fee schedule","23.93","35.19",
"Temozolomide injection","J9328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","23.93",,,,,,,"fee schedule","23.93","35.19",
"Temozolomide injection","J9328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","23.93",,,,,,,"fee schedule","23.93","35.19",
"Temozolomide injection","J9328","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","35.19",,,,,,,"fee schedule","23.93","35.19",
"Temsirolimus injection","J9330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","69.73",,,,,,,"fee schedule","69.73","153.17",
"Temsirolimus injection","J9330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","69.73",,,,,,,"fee schedule","69.73","153.17",
"Temsirolimus injection","J9330","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","69.73",,,,,,,"fee schedule","69.73","153.17",
"Temsirolimus injection","J9330","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","153.17",,,,,,,"fee schedule","69.73","153.17",
"Inj sirolimus prot part 1 mg","J9331","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","270.55",,,,,,,"fee schedule","270.55","270.55",
"Inj sirolimus prot part 1 mg","J9331","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","270.55",,,,,,,"fee schedule","270.55","270.55",
"Inj sirolimus prot part 1 mg","J9331","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","270.55",,,,,,,"fee schedule","270.55","270.55",
"Inj efgartigimod 2mg","J9332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","74.46",,,,,,,"fee schedule","74.46","74.46",
"Inj efgartigimod 2mg","J9332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","74.46",,,,,,,"fee schedule","74.46","74.46",
"Inj efgartigimod 2mg","J9332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","74.46",,,,,,,"fee schedule","74.46","74.46",
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","52.54",,,,,,,"fee schedule","52.54","52.54",
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","52.54",,,,,,,"fee schedule","52.54","52.54",
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","52.54",,,,,,,"fee schedule","52.54","52.54",
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","76.75",,,,,,,"fee schedule","76.75","76.75",
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","76.75",,,,,,,"fee schedule","76.75","76.75",
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","76.75",,,,,,,"fee schedule","76.75","76.75",
"Thiotepa injection","J9340","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","563.61",,,,,,,"fee schedule","563.61","1491.9",
"Thiotepa injection","J9340","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","563.61",,,,,,,"fee schedule","563.61","1491.9",
"Thiotepa injection","J9340","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","563.61",,,,,,,"fee schedule","563.61","1491.9",
"Thiotepa injection","J9340","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1491.9",,,,,,,"fee schedule","563.61","1491.9",
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","68.39",,,,,,,"fee schedule","68.39","68.39",
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","68.39",,,,,,,"fee schedule","68.39","68.39",
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","68.39",,,,,,,"fee schedule","68.39","68.39",
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","317.96",,,,,,,"fee schedule","317.96","317.96",
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","317.96",,,,,,,"fee schedule","317.96","317.96",
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","317.96",,,,,,,"fee schedule","317.96","317.96",
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1476.21",,,,,,,"fee schedule","1476.21","1476.21",
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1476.21",,,,,,,"fee schedule","1476.21","1476.21",
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1476.21",,,,,,,"fee schedule","1476.21","1476.21",
"Inj., tafasitamab-cxix","J9349","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","32.03",,,,,,,"fee schedule","32.03","32.03",
"Inj., tafasitamab-cxix","J9349","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","32.03",,,,,,,"fee schedule","32.03","32.03",
"Inj., tafasitamab-cxix","J9349","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","32.03",,,,,,,"fee schedule","32.03","32.03",
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1474.2",,,,,,,"fee schedule","1474.2","1474.2",
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1474.2",,,,,,,"fee schedule","1474.2","1474.2",
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1474.2",,,,,,,"fee schedule","1474.2","1474.2",
"Topotecan injection","J9351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.93",,,,,,,"fee schedule","2.93","2.97",
"Topotecan injection","J9351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.93",,,,,,,"fee schedule","2.93","2.97",
"Topotecan injection","J9351","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.93",,,,,,,"fee schedule","2.93","2.97",
"Topotecan injection","J9351","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.97",,,,,,,"fee schedule","2.93","2.97",
"Injection trabectedin 0.1mg","J9352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","836.81",,,,,,,"fee schedule","836.81","1060.98",
"Injection trabectedin 0.1mg","J9352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","836.81",,,,,,,"fee schedule","836.81","1060.98",
"Injection trabectedin 0.1mg","J9352","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","836.81",,,,,,,"fee schedule","836.81","1060.98",
"Injection trabectedin 0.1mg","J9352","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1060.98",,,,,,,"fee schedule","836.81","1060.98",
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","111.62",,,,,,,"fee schedule","111.62","111.62",
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","111.62",,,,,,,"fee schedule","111.62","111.62",
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","111.62",,,,,,,"fee schedule","111.62","111.62",
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","101.68",,,,,,,"fee schedule","94.54","108.7",
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","100.67",,,,,,,"fee schedule","94.54","108.7",
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","94.54",,,,,,,"fee schedule","94.54","108.7",
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","94.54",,,,,,,"fee schedule","94.54","108.7",
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","94.54",,,,,,,"fee schedule","94.54","108.7",
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","108.7",,,,,,,"fee schedule","94.54","108.7",
"Trastuzumab injection","J9355","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","303.12",,,,,,,"fee schedule","174.09","353.28",
"Trastuzumab injection","J9355","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","300.12",,,,,,,"fee schedule","174.09","353.28",
"Trastuzumab injection","J9355","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","174.09",,,,,,,"fee schedule","174.09","353.28",
"Trastuzumab injection","J9355","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","174.09",,,,,,,"fee schedule","174.09","353.28",
"Trastuzumab injection","J9355","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","174.09",,,,,,,"fee schedule","174.09","353.28",
"Trastuzumab injection","J9355","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","353.28",,,,,,,"fee schedule","174.09","353.28",
"Inj. herceptin hylecta, 10mg","J9356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","144.71",,,,,,,"fee schedule","144.71","264.42",
"Inj. herceptin hylecta, 10mg","J9356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","144.71",,,,,,,"fee schedule","144.71","264.42",
"Inj. herceptin hylecta, 10mg","J9356","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","144.71",,,,,,,"fee schedule","144.71","264.42",
"Inj. herceptin hylecta, 10mg","J9356","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","264.42",,,,,,,"fee schedule","144.71","264.42",
"Valrubicin injection","J9357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3322.47",,,,,,,"fee schedule","3322.47","4756.22",
"Valrubicin injection","J9357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3322.47",,,,,,,"fee schedule","3322.47","4756.22",
"Valrubicin injection","J9357","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3322.47",,,,,,,"fee schedule","3322.47","4756.22",
"Valrubicin injection","J9357","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4756.22",,,,,,,"fee schedule","3322.47","4756.22",
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","66.47",,,,,,,"fee schedule","58.01","66.47",
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","66.47",,,,,,,"fee schedule","58.01","66.47",
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","66.47",,,,,,,"fee schedule","58.01","66.47",
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","58.01",,,,,,,"fee schedule","58.01","66.47",
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","487.59",,,,,,,"fee schedule","487.59","487.59",
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","487.59",,,,,,,"fee schedule","487.59","487.59",
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","487.59",,,,,,,"fee schedule","487.59","487.59",
"Vinblastine sulfate inj","J9360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","11.81",,,,,,,"fee schedule","11.81","13.13",
"Vinblastine sulfate inj","J9360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","11.81",,,,,,,"fee schedule","11.81","13.13",
"Vinblastine sulfate inj","J9360","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","11.81",,,,,,,"fee schedule","11.81","13.13",
"Vinblastine sulfate inj","J9360","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","13.13",,,,,,,"fee schedule","11.81","13.13",
"Vincristine sulfate 1 MG inj","J9370","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","18.85",,,,,,,"fee schedule","16.51","18.85",
"Vincristine sulfate 1 MG inj","J9370","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","18.85",,,,,,,"fee schedule","16.51","18.85",
"Vincristine sulfate 1 MG inj","J9370","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","18.85",,,,,,,"fee schedule","16.51","18.85",
"Vincristine sulfate 1 MG inj","J9370","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","16.51",,,,,,,"fee schedule","16.51","18.85",
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","74.56",,,,,,,"fee schedule","74.56","74.56",
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","74.56",,,,,,,"fee schedule","74.56","74.56",
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","74.56",,,,,,,"fee schedule","74.56","74.56",
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","85.81",,,,,,,"fee schedule","85.81","85.81",
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","85.81",,,,,,,"fee schedule","85.81","85.81",
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","85.81",,,,,,,"fee schedule","85.81","85.81",
"Vinorelbine tartrate inj","J9390","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15.15",,,,,,,"fee schedule","12.63","15.15",
"Vinorelbine tartrate inj","J9390","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15.15",,,,,,,"fee schedule","12.63","15.15",
"Vinorelbine tartrate inj","J9390","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15.15",,,,,,,"fee schedule","12.63","15.15",
"Vinorelbine tartrate inj","J9390","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","12.63",,,,,,,"fee schedule","12.63","15.15",
"Inj, fulvestrant (fresenius)","J9394","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7.64",,,,,,,"fee schedule","7.64","7.64",
"Inj, fulvestrant (fresenius)","J9394","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7.64",,,,,,,"fee schedule","7.64","7.64",
"Inj, fulvestrant (fresenius)","J9394","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7.64",,,,,,,"fee schedule","7.64","7.64",
"Injection, Fulvestrant","J9395","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","167.85",,,,,,,"fee schedule","15.86","191.43",
"Injection, Fulvestrant","J9395","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","169.52",,,,,,,"fee schedule","15.86","191.43",
"Injection, Fulvestrant","J9395","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15.86",,,,,,,"fee schedule","15.86","191.43",
"Injection, Fulvestrant","J9395","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15.86",,,,,,,"fee schedule","15.86","191.43",
"Injection, Fulvestrant","J9395","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15.86",,,,,,,"fee schedule","15.86","191.43",
"Injection, Fulvestrant","J9395","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","191.43",,,,,,,"fee schedule","15.86","191.43",
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","19.09",,,,,,,"fee schedule","19.09","28.65",
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","19.09",,,,,,,"fee schedule","19.09","28.65",
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","19.09",,,,,,,"fee schedule","19.09","28.65",
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","28.65",,,,,,,"fee schedule","19.09","28.65",
"Porfimer sodium injection","J9600","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","74101.05",,,,,,,"fee schedule","74101.05","74101.05",
"Inj bulking agent anal canal","L8605","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2903.98",,,,,,,"fee schedule","2903.98","2903.98",
"Inj vocal cord bulking agent","L8607","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","173.9",,,,,,,"fee schedule","173.9","173.9",
"Albumin (human),5%, 50ml","P9041","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","24.41",,,,,,,"fee schedule","24.41","35.58",
"Albumin (human),5%, 50ml","P9041","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","24.41",,,,,,,"fee schedule","24.41","35.58",
"Albumin (human),5%, 50ml","P9041","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","24.41",,,,,,,"fee schedule","24.41","35.58",
"Albumin (human),5%, 50ml","P9041","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","35.58",,,,,,,"fee schedule","24.41","35.58",
"Albumin (human), 5%, 250 ml","P9045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","122.08",,,,,,,"fee schedule","122.08","177.83",
"Albumin (human), 5%, 250 ml","P9045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","122.08",,,,,,,"fee schedule","122.08","177.83",
"Albumin (human), 5%, 250 ml","P9045","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","122.08",,,,,,,"fee schedule","122.08","177.83",
"Albumin (human), 5%, 250 ml","P9045","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","177.83",,,,,,,"fee schedule","122.08","177.83",
"Albumin (human), 25%, 20 ml","P9046","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","48.83",,,,,,,"fee schedule","48.83","71.11",
"Albumin (human), 25%, 20 ml","P9046","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","48.83",,,,,,,"fee schedule","48.83","71.11",
"Albumin (human), 25%, 20 ml","P9046","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","48.83",,,,,,,"fee schedule","48.83","71.11",
"Albumin (human), 25%, 20 ml","P9046","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","71.11",,,,,,,"fee schedule","48.83","71.11",
"Albumin (human), 25%, 50ml","P9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","122.08",,,,,,,"fee schedule","122.08","177.83",
"Albumin (human), 25%, 50ml","P9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","122.08",,,,,,,"fee schedule","122.08","177.83",
"Albumin (human), 25%, 50ml","P9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","122.08",,,,,,,"fee schedule","122.08","177.83",
"Albumin (human), 25%, 50ml","P9047","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","177.83",,,,,,,"fee schedule","122.08","177.83",
"Ferumoxytol, non-esrd","Q0138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.75",,,,,,,"fee schedule","0.75","3.64",
"Ferumoxytol, non-esrd","Q0138","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.64",,,,,,,"fee schedule","0.75","3.64",
"Ferumoxytol, non-esrd","Q0138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.75",,,,,,,"fee schedule","0.75","3.64",
"Ferumoxytol, non-esrd","Q0138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.75",,,,,,,"fee schedule","0.75","3.64",
"Ferumoxytol, esrd use","Q0139","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.64",,,,,,,"fee schedule","0.75","3.64",
"Ferumoxytol, esrd use","Q0139","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.75",,,,,,,"fee schedule","0.75","3.64",
"Ferumoxytol, esrd use","Q0139","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.75",,,,,,,"fee schedule","0.75","3.64",
"Ferumoxytol, esrd use","Q0139","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.75",,,,,,,"fee schedule","0.75","3.64",
"Azithromycin dihydrate, oral","Q0144","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","47.71",,,,,,,"fee schedule","47.71","47.71",
"Ondansetron oral","Q0162","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.03",,,,,,,"fee schedule","0.03","0.11",
"Ondansetron oral","Q0162","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.03",,,,,,,"fee schedule","0.03","0.11",
"Ondansetron oral","Q0162","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.03",,,,,,,"fee schedule","0.03","0.11",
"Ondansetron oral","Q0162","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.11",,,,,,,"fee schedule","0.03","0.11",
"Diphenhydramine HCl 50mg","Q0163","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.47",,,,,,,"fee schedule","3.47","3.47",
"Prochlorperazine maleate 5mg","Q0164","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.8",,,,,,,"fee schedule","0.8","0.8",
"Granisetron HCl 1 mg oral","Q0166","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.47",,,,,,,"fee schedule","2.47","2.47",
"Dronabinol 2.5mg oral","Q0167","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3.39",,,,,,,"fee schedule","2.63","3.39",
"Dronabinol 2.5mg oral","Q0167","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3.39",,,,,,,"fee schedule","2.63","3.39",
"Dronabinol 2.5mg oral","Q0167","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3.39",,,,,,,"fee schedule","2.63","3.39",
"Dronabinol 2.5mg oral","Q0167","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.63",,,,,,,"fee schedule","2.63","3.39",
"Promethazine HCl 12.5mg oral","Q0169","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.99",,,,,,,"fee schedule","0.99","0.99",
"Trimethobenzamide HCl 250mg","Q0173","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.44",,,,,,,"fee schedule","2.44","2.44",
"Thiethylperazine maleate10mg","Q0174","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.44",,,,,,,"fee schedule","2.44","2.44",
"Perphenazine 4mg oral","Q0175","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.44",,,,,,,"fee schedule","2.44","2.44",
"Hydroxyzine pamoate 25mg","Q0177","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7.36",,,,,,,"fee schedule","7.36","7.36",
"Dolasetron mesylate oral","Q0180","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","487.43",,,,,,,"fee schedule","487.43","487.43",
"Inj, pemivibart, 4500 mg","Q0224","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","15142.05",,,,,,,"fee schedule","15142.05","15142.05",
"Inj, pemivibart, 4500 mg","Q0224","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","15142.05",,,,,,,"fee schedule","15142.05","15142.05",
"Inj, pemivibart, 4500 mg","Q0224","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","15142.05",,,,,,,"fee schedule","15142.05","15142.05",
"Tocilizumab for covid-19","Q0249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17.41",,,,,,,"fee schedule","17.41","17.41",
"Tocilizumab for covid-19","Q0249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17.41",,,,,,,"fee schedule","17.41","17.41",
"Tocilizumab for covid-19","Q0249","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17.41",,,,,,,"fee schedule","17.41","17.41",
"Sermorelin acetate injection","Q0515","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4.86",,,,,,,"fee schedule","4.86","4.86",
"Bladder calculi irrig sol","Q2004","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","52.63",,,,,,,"fee schedule","52.63","52.63",
"Fosphenytoin inj pe","Q2009","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6.23",,,,,,,"fee schedule","6.23","6.23",
"Teniposide, 50 mg","Q2017","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","8969.93",,,,,,,"fee schedule","8969.93","8969.93",
"Radiesse injection","Q2026","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","752.97",,,,,,,"fee schedule","752.97","752.97",
"Inj, sculptra, 0.5mg","Q2028","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10.82",,,,,,,"fee schedule","10.82","10.82",
"Afluria vacc, 3 yrs & >, im","Q2035","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","42.83",,,,,,,"fee schedule","42.83","42.83",
"Flulaval vacc, 3 yrs & >, im","Q2036","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","63.65",,,,,,,"fee schedule","63.65","63.65",
"Fluvirin vacc, 3 yrs & >, im","Q2037","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","45.26",,,,,,,"fee schedule","45.26","45.26",
"Fluzone vacc, 3 yrs & >, im","Q2038","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","199.87",,,,,,,"fee schedule","199.87","199.87",
"Influenza virus vaccine, nos","Q2039","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","99.18",,,,,,,"fee schedule","99.18","99.18",
"Axicabtagene ciloleucel car+","Q2041","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1340483.41",,,,,,,"fee schedule","1340483.41","1340483.41",
"Tisagenlecleucel car-pos t","Q2042","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1476857.1",,,,,,,"fee schedule","1476857.1","1476857.1",
"Sipuleucel-t auto cd54+","Q2043","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","131139.34",,,,,,,"fee schedule","131139.34","162691.22",
"Sipuleucel-t auto cd54+","Q2043","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","131139.34",,,,,,,"fee schedule","131139.34","162691.22",
"Sipuleucel-t auto cd54+","Q2043","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","131139.34",,,,,,,"fee schedule","131139.34","162691.22",
"Sipuleucel-t auto cd54+","Q2043","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","162691.22",,,,,,,"fee schedule","131139.34","162691.22",
"Imported Lipodox inj","Q2049","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1634.36",,,,,,,"fee schedule","1634.36","1634.36",
"Doxorubicin inj 10mg","Q2050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","345.94",,,,,,,"fee schedule","345.94","1033.12",
"Doxorubicin inj 10mg","Q2050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","345.94",,,,,,,"fee schedule","345.94","1033.12",
"Doxorubicin inj 10mg","Q2050","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","345.94",,,,,,,"fee schedule","345.94","1033.12",
"Doxorubicin inj 10mg","Q2050","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1033.12",,,,,,,"fee schedule","345.94","1033.12",
"Brachytherapy radioelements","Q3001","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","196.98",,,,,,,"fee schedule","196.98","196.98",
"Inj beta interferon im 1 mcg","Q3027","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","180.44",,,,,,,"fee schedule","180.44","180.44",
"Inj beta interferon sq 1 mcg","Q3028","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","119.89",,,,,,,"fee schedule","119.89","119.89",
"Iloprost non-comp unit dose","Q4074","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","342.16",,,,,,,"fee schedule","342.16","475.09",
"Iloprost non-comp unit dose","Q4074","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","342.16",,,,,,,"fee schedule","342.16","475.09",
"Iloprost non-comp unit dose","Q4074","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","342.16",,,,,,,"fee schedule","342.16","475.09",
"Iloprost non-comp unit dose","Q4074","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","475.09",,,,,,,"fee schedule","342.16","475.09",
"Epoetin alfa, 100 units ESRD","Q4081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.63",,,,,,,"fee schedule","1.63","3.38",
"Epoetin alfa, 100 units ESRD","Q4081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.63",,,,,,,"fee schedule","1.63","3.38",
"Epoetin alfa, 100 units ESRD","Q4081","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.63",,,,,,,"fee schedule","1.63","3.38",
"Epoetin alfa, 100 units ESRD","Q4081","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.38",,,,,,,"fee schedule","1.63","3.38",
"Apligraf","Q4101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","69.83",,,,,,,"fee schedule","69.83","103.33",
"Apligraf","Q4101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","69.83",,,,,,,"fee schedule","69.83","103.33",
"Apligraf","Q4101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","69.83",,,,,,,"fee schedule","69.83","103.33",
"Apligraf","Q4101","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","103.33",,,,,,,"fee schedule","69.83","103.33",
"Oasis wound matrix","Q4102","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","27.63",,,,,,,"fee schedule","27.63","36.53",
"Oasis wound matrix","Q4102","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","27.63",,,,,,,"fee schedule","27.63","36.53",
"Oasis wound matrix","Q4102","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","27.63",,,,,,,"fee schedule","27.63","36.53",
"Oasis wound matrix","Q4102","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","36.53",,,,,,,"fee schedule","27.63","36.53",
"Oasis burn matrix","Q4103","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","28.82",,,,,,,"fee schedule","28.82","28.82",
"Oasis burn matrix","Q4103","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","28.82",,,,,,,"fee schedule","28.82","28.82",
"Oasis burn matrix","Q4103","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","28.82",,,,,,,"fee schedule","28.82","28.82",
"Integra bmwd","Q4104","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","114.52",,,,,,,"fee schedule","114.52","247.13",
"Integra bmwd","Q4104","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","114.52",,,,,,,"fee schedule","114.52","247.13",
"Integra bmwd","Q4104","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","114.52",,,,,,,"fee schedule","114.52","247.13",
"Integra bmwd","Q4104","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","247.13",,,,,,,"fee schedule","114.52","247.13",
"Integra drt or omnigraft","Q4105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","53.47",,,,,,,"fee schedule","53.47","201.15",
"Integra drt or omnigraft","Q4105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","53.47",,,,,,,"fee schedule","53.47","201.15",
"Integra drt or omnigraft","Q4105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","53.47",,,,,,,"fee schedule","53.47","201.15",
"Integra drt or omnigraft","Q4105","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","201.15",,,,,,,"fee schedule","53.47","201.15",
"Dermagraft","Q4106","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","108.83",,,,,,,"fee schedule","108.83","108.83",
"Graftjacket","Q4107","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","462.68",,,,,,,"fee schedule","462.68","462.68",
"Integra matrix","Q4108","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","116.1",,,,,,,"fee schedule","116.1","226.27",
"Integra matrix","Q4108","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","116.1",,,,,,,"fee schedule","116.1","226.27",
"Integra matrix","Q4108","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","116.1",,,,,,,"fee schedule","116.1","226.27",
"Integra matrix","Q4108","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","226.27",,,,,,,"fee schedule","116.1","226.27",
"Primatrix","Q4110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","150.43",,,,,,,"fee schedule","149.99","150.43",
"Primatrix","Q4110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","150.43",,,,,,,"fee schedule","149.99","150.43",
"Primatrix","Q4110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","150.43",,,,,,,"fee schedule","149.99","150.43",
"Primatrix","Q4110","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","149.99",,,,,,,"fee schedule","149.99","150.43",
"Gammagraft","Q4111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","17.48",,,,,,,"fee schedule","17.48","23.63",
"Gammagraft","Q4111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","17.48",,,,,,,"fee schedule","17.48","23.63",
"Gammagraft","Q4111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","17.48",,,,,,,"fee schedule","17.48","23.63",
"Gammagraft","Q4111","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","23.63",,,,,,,"fee schedule","17.48","23.63",
"Graftjacket xpress","Q4113","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","6772.25",,,,,,,"fee schedule","6772.25","6772.25",
"Integra flowable wound matri","Q4114","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3437",,,,,,,"fee schedule","3437","7028.67",
"Integra flowable wound matri","Q4114","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3437",,,,,,,"fee schedule","3437","7028.67",
"Integra flowable wound matri","Q4114","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3437",,,,,,,"fee schedule","3437","7028.67",
"Integra flowable wound matri","Q4114","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7028.67",,,,,,,"fee schedule","3437","7028.67",
"Alloskin","Q4115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","28.48",,,,,,,"fee schedule","28.48","66.31",
"Alloskin","Q4115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","28.48",,,,,,,"fee schedule","28.48","66.31",
"Alloskin","Q4115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","28.48",,,,,,,"fee schedule","28.48","66.31",
"Alloskin","Q4115","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","66.31",,,,,,,"fee schedule","28.48","66.31",
"Hyalomatrix","Q4117","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","102.75",,,,,,,"fee schedule","102.75","102.75",
"Matristem micromatrix","Q4118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5.87",,,,,,,"fee schedule","5.87","22.71",
"Matristem micromatrix","Q4118","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","22.71",,,,,,,"fee schedule","5.87","22.71",
"Matristem micromatrix","Q4118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5.87",,,,,,,"fee schedule","5.87","22.71",
"Matristem micromatrix","Q4118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5.87",,,,,,,"fee schedule","5.87","22.71",
"Theraskin","Q4121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","119.11",,,,,,,"fee schedule","119.11","144.18",
"Theraskin","Q4121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","119.11",,,,,,,"fee schedule","119.11","144.18",
"Theraskin","Q4121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","119.11",,,,,,,"fee schedule","119.11","144.18",
"Theraskin","Q4121","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","144.18",,,,,,,"fee schedule","119.11","144.18",
"Dermacell","Q4122","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","389.24",,,,,,,"fee schedule","389.24","389.24",
"Alloskin","Q4123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","164.57",,,,,,,"fee schedule","164.57","270.47",
"Alloskin","Q4123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","164.57",,,,,,,"fee schedule","164.57","270.47",
"Alloskin","Q4123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","164.57",,,,,,,"fee schedule","164.57","270.47",
"Alloskin","Q4123","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","270.47",,,,,,,"fee schedule","164.57","270.47",
"Oasis tri-layer wound matrix","Q4124","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","20.91",,,,,,,"fee schedule","20.91","54.88",
"Oasis tri-layer wound matrix","Q4124","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","20.91",,,,,,,"fee schedule","20.91","54.88",
"Oasis tri-layer wound matrix","Q4124","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","20.91",,,,,,,"fee schedule","20.91","54.88",
"Oasis tri-layer wound matrix","Q4124","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","54.88",,,,,,,"fee schedule","20.91","54.88",
"Memoderm/derma/tranz/integup","Q4126","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","145.6",,,,,,,"fee schedule","145.6","314.29",
"Memoderm/derma/tranz/integup","Q4126","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","145.6",,,,,,,"fee schedule","145.6","314.29",
"Memoderm/derma/tranz/integup","Q4126","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","145.6",,,,,,,"fee schedule","145.6","314.29",
"Memoderm/derma/tranz/integup","Q4126","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","314.29",,,,,,,"fee schedule","145.6","314.29",
"Talymed","Q4127","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","157.52",,,,,,,"fee schedule","109.17","157.52",
"Talymed","Q4127","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","157.52",,,,,,,"fee schedule","109.17","157.52",
"Talymed","Q4127","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","157.52",,,,,,,"fee schedule","109.17","157.52",
"Talymed","Q4127","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","109.17",,,,,,,"fee schedule","109.17","157.52",
"Flexhd/allopatchhd/matrixhd","Q4128","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","56.27",,,,,,,"fee schedule","56.27","56.27",
"Flexhd/allopatchhd/matrixhd","Q4128","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","56.27",,,,,,,"fee schedule","56.27","56.27",
"Flexhd/allopatchhd/matrixhd","Q4128","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","56.27",,,,,,,"fee schedule","56.27","56.27",
"Grafix core","Q4132","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","86.25",,,,,,,"fee schedule","86.25","400.78",
"Grafix core","Q4132","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","86.25",,,,,,,"fee schedule","86.25","400.78",
"Grafix core","Q4132","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","86.25",,,,,,,"fee schedule","86.25","400.78",
"Grafix core","Q4132","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","400.78",,,,,,,"fee schedule","86.25","400.78",
"Grafix prime","Q4133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","313.64",,,,,,,"fee schedule","313.64","472.93",
"Grafix prime","Q4133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","313.64",,,,,,,"fee schedule","313.64","472.93",
"Grafix prime","Q4133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","313.64",,,,,,,"fee schedule","313.64","472.93",
"Grafix prime","Q4133","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","472.93",,,,,,,"fee schedule","313.64","472.93",
"Amnioexcel or biodexcel, 1cm","Q4137","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","235.02",,,,,,,"fee schedule","235.02","242.93",
"Amnioexcel or biodexcel, 1cm","Q4137","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","235.02",,,,,,,"fee schedule","235.02","242.93",
"Amnioexcel or biodexcel, 1cm","Q4137","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","235.02",,,,,,,"fee schedule","235.02","242.93",
"Amnioexcel or biodexcel, 1cm","Q4137","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","242.93",,,,,,,"fee schedule","235.02","242.93",
"Biodfence dryflex, 1cm","Q4138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","216.79",,,,,,,"fee schedule","216.79","216.79",
"Biodfence dryflex, 1cm","Q4138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","216.79",,,,,,,"fee schedule","216.79","216.79",
"Biodfence dryflex, 1cm","Q4138","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","216.79",,,,,,,"fee schedule","216.79","216.79",
"Biodfence 1cm","Q4140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","388.51",,,,,,,"fee schedule","388.51","388.51",
"Biodfence 1cm","Q4140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","388.51",,,,,,,"fee schedule","388.51","388.51",
"Biodfence 1cm","Q4140","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","388.51",,,,,,,"fee schedule","388.51","388.51",
"Alloskin ac, 1 cm","Q4141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","87.09",,,,,,,"fee schedule","87.09","395.86",
"Alloskin ac, 1 cm","Q4141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","87.09",,,,,,,"fee schedule","87.09","395.86",
"Alloskin ac, 1 cm","Q4141","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","87.09",,,,,,,"fee schedule","87.09","395.86",
"Alloskin ac, 1 cm","Q4141","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","395.86",,,,,,,"fee schedule","87.09","395.86",
"Repriza, 1cm","Q4143","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","78.02",,,,,,,"fee schedule","78.02","78.02",
"Repriza, 1cm","Q4143","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","78.02",,,,,,,"fee schedule","78.02","78.02",
"Repriza, 1cm","Q4143","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","78.02",,,,,,,"fee schedule","78.02","78.02",
"Epifix, inj, 1mg","Q4145","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","55.18",,,,,,,"fee schedule","55.18","55.18",
"Neox 1k, 1cm","Q4148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","295.39",,,,,,,"fee schedule","295.39","1027.32",
"Neox 1k, 1cm","Q4148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","295.39",,,,,,,"fee schedule","295.39","1027.32",
"Neox 1k, 1cm","Q4148","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","295.39",,,,,,,"fee schedule","295.39","1027.32",
"Neox 1k, 1cm","Q4148","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1027.32",,,,,,,"fee schedule","295.39","1027.32",
"Excellagen, 0.1 cc","Q4149","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","589.92",,,,,,,"fee schedule","589.92","589.92",
"Allowrap ds or dry 1 sq cm","Q4150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","190.35",,,,,,,"fee schedule","190.35","190.35",
"Allowrap ds or dry 1 sq cm","Q4150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","190.35",,,,,,,"fee schedule","190.35","190.35",
"Allowrap ds or dry 1 sq cm","Q4150","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","190.35",,,,,,,"fee schedule","190.35","190.35",
"Amnioband, guardian 1 sq cm","Q4151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","313.89",,,,,,,"fee schedule","313.89","435.15",
"Amnioband, guardian 1 sq cm","Q4151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","313.89",,,,,,,"fee schedule","313.89","435.15",
"Amnioband, guardian 1 sq cm","Q4151","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","313.89",,,,,,,"fee schedule","313.89","435.15",
"Amnioband, guardian 1 sq cm","Q4151","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","435.15",,,,,,,"fee schedule","313.89","435.15",
"Dermapure 1 square cm","Q4152","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","125.63",,,,,,,"fee schedule","125.63","425.86",
"Dermapure 1 square cm","Q4152","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","125.63",,,,,,,"fee schedule","125.63","425.86",
"Dermapure 1 square cm","Q4152","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","125.63",,,,,,,"fee schedule","125.63","425.86",
"Dermapure 1 square cm","Q4152","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","425.86",,,,,,,"fee schedule","125.63","425.86",
"Dermavest, plurivest sq cm","Q4153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","294.58",,,,,,,"fee schedule","294.58","1125.73",
"Dermavest, plurivest sq cm","Q4153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","294.58",,,,,,,"fee schedule","294.58","1125.73",
"Dermavest, plurivest sq cm","Q4153","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","294.58",,,,,,,"fee schedule","294.58","1125.73",
"Dermavest, plurivest sq cm","Q4153","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1125.73",,,,,,,"fee schedule","294.58","1125.73",
"Biovance 1 square cm","Q4154","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","307.42",,,,,,,"fee schedule","307.42","397.39",
"Biovance 1 square cm","Q4154","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","307.42",,,,,,,"fee schedule","307.42","397.39",
"Biovance 1 square cm","Q4154","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","307.42",,,,,,,"fee schedule","307.42","397.39",
"Biovance 1 square cm","Q4154","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","397.39",,,,,,,"fee schedule","307.42","397.39",
"Neoxflo or clarixflo 1 mg","Q4155","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","60.51",,,,,,,"fee schedule","60.51","60.51",
"Neoxflo or clarixflo 1 mg","Q4155","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","60.51",,,,,,,"fee schedule","60.51","60.51",
"Neoxflo or clarixflo 1 mg","Q4155","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","60.51",,,,,,,"fee schedule","60.51","60.51",
"Neox 100 1 square cm","Q4156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","148.93",,,,,,,"fee schedule","148.93","739.1",
"Neox 100 1 square cm","Q4156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","148.93",,,,,,,"fee schedule","148.93","739.1",
"Neox 100 1 square cm","Q4156","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","148.93",,,,,,,"fee schedule","148.93","739.1",
"Neox 100 1 square cm","Q4156","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","739.1",,,,,,,"fee schedule","148.93","739.1",
"Revitalon 1 square cm","Q4157","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","687.91",,,,,,,"fee schedule","687.91","687.91",
"Marigen 1 square cm","Q4158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","146.32",,,,,,,"fee schedule","146.32","720.92",
"Marigen 1 square cm","Q4158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","146.32",,,,,,,"fee schedule","146.32","720.92",
"Marigen 1 square cm","Q4158","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","146.32",,,,,,,"fee schedule","146.32","720.92",
"Marigen 1 square cm","Q4158","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","720.92",,,,,,,"fee schedule","146.32","720.92",
"Affinity1 square cm","Q4159","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","604.74",,,,,,,"fee schedule","604.74","4294.24",
"Affinity1 square cm","Q4159","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","604.74",,,,,,,"fee schedule","604.74","4294.24",
"Affinity1 square cm","Q4159","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","604.74",,,,,,,"fee schedule","604.74","4294.24",
"Affinity1 square cm","Q4159","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","4294.24",,,,,,,"fee schedule","604.74","4294.24",
"Nushield 1 square cm","Q4160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","213.1",,,,,,,"fee schedule","213.1","303.09",
"Nushield 1 square cm","Q4160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","213.1",,,,,,,"fee schedule","213.1","303.09",
"Nushield 1 square cm","Q4160","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","213.1",,,,,,,"fee schedule","213.1","303.09",
"Nushield 1 square cm","Q4160","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","303.09",,,,,,,"fee schedule","213.1","303.09",
"Bio-connekt per square cm","Q4161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4263.41",,,,,,,"fee schedule","4263.41","4263.41",
"Bio-connekt per square cm","Q4161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4263.41",,,,,,,"fee schedule","4263.41","4263.41",
"Bio-connekt per square cm","Q4161","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4263.41",,,,,,,"fee schedule","4263.41","4263.41",
"Amnio bio and woundex flow","Q4162","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","7954.65",,,,,,,"fee schedule","7954.65","7954.65",
"Amnio bio and woundex sq cm","Q4163","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","419.02",,,,,,,"fee schedule","419.02","2034.34",
"Amnio bio and woundex sq cm","Q4163","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","419.02",,,,,,,"fee schedule","419.02","2034.34",
"Amnio bio and woundex sq cm","Q4163","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","419.02",,,,,,,"fee schedule","419.02","2034.34",
"Amnio bio and woundex sq cm","Q4163","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2034.34",,,,,,,"fee schedule","419.02","2034.34",
"Helicoll, per square cm","Q4164","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","740.95",,,,,,,"fee schedule","740.95","740.95",
"Helicoll, per square cm","Q4164","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","740.95",,,,,,,"fee schedule","740.95","740.95",
"Helicoll, per square cm","Q4164","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","740.95",,,,,,,"fee schedule","740.95","740.95",
"Keramatrix, per square cm","Q4165","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","43.96",,,,,,,"fee schedule","43.96","43.96",
"Cytal, per square centimeter","Q4166","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","49.44",,,,,,,"fee schedule","49.44","109.67",
"Cytal, per square centimeter","Q4166","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","49.44",,,,,,,"fee schedule","49.44","109.67",
"Cytal, per square centimeter","Q4166","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","49.44",,,,,,,"fee schedule","49.44","109.67",
"Cytal, per square centimeter","Q4166","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","109.67",,,,,,,"fee schedule","49.44","109.67",
"Truskin, per sq centimeter","Q4167","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","410.3",,,,,,,"fee schedule","410.3","410.3",
"Artacent wound, per sq cm","Q4169","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1226.06",,,,,,,"fee schedule","1226.06","1226.06",
"Cygnus, per sq cm","Q4170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1022.9",,,,,,,"fee schedule","1022.9","1022.9",
"Cygnus, per sq cm","Q4170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1022.9",,,,,,,"fee schedule","1022.9","1022.9",
"Cygnus, per sq cm","Q4170","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1022.9",,,,,,,"fee schedule","1022.9","1022.9",
"Interfyl, 1 mg","Q4171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","27.89",,,,,,,"fee schedule","27.89","27.89",
"Interfyl, 1 mg","Q4171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","27.89",,,,,,,"fee schedule","27.89","27.89",
"Interfyl, 1 mg","Q4171","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","27.89",,,,,,,"fee schedule","27.89","27.89",
"Palingen or palingen xplus","Q4173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","829.17",,,,,,,"fee schedule","829.17","829.17",
"Palingen or palingen xplus","Q4173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","829.17",,,,,,,"fee schedule","829.17","829.17",
"Palingen or palingen xplus","Q4173","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","829.17",,,,,,,"fee schedule","829.17","829.17",
"Miroderm","Q4175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","157.68",,,,,,,"fee schedule","157.68","322.2",
"Miroderm","Q4175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","157.68",,,,,,,"fee schedule","157.68","322.2",
"Miroderm","Q4175","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","157.68",,,,,,,"fee schedule","157.68","322.2",
"Miroderm","Q4175","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","322.2",,,,,,,"fee schedule","157.68","322.2",
"Neopatch, per sq centimeter","Q4176","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","407.6",,,,,,,"fee schedule","407.6","407.6",
"Floweramnioflo, 0.1 cc","Q4177","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","610.27",,,,,,,"fee schedule","610.27","610.27",
"Floweramniopatch, per sq cm","Q4178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","211.67",,,,,,,"fee schedule","211.67","763.21",
"Floweramniopatch, per sq cm","Q4178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","211.67",,,,,,,"fee schedule","211.67","763.21",
"Floweramniopatch, per sq cm","Q4178","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","211.67",,,,,,,"fee schedule","211.67","763.21",
"Floweramniopatch, per sq cm","Q4178","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","763.21",,,,,,,"fee schedule","211.67","763.21",
"Revita, per sq cm","Q4180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2369.33",,,,,,,"fee schedule","813.57","2369.33",
"Revita, per sq cm","Q4180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2369.33",,,,,,,"fee schedule","813.57","2369.33",
"Revita, per sq cm","Q4180","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2369.33",,,,,,,"fee schedule","813.57","2369.33",
"Revita, per sq cm","Q4180","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","813.57",,,,,,,"fee schedule","813.57","2369.33",
"Amnio wound, per square cm","Q4181","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","552.76",,,,,,,"fee schedule","552.76","552.76",
"Surgigraft, 1 sq cm","Q4183","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","675.11",,,,,,,"fee schedule","675.11","675.11",
"Cellesta, 1 sq cm","Q4184","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","184.09",,,,,,,"fee schedule","184.09","986.95",
"Cellesta, 1 sq cm","Q4184","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","184.09",,,,,,,"fee schedule","184.09","986.95",
"Cellesta, 1 sq cm","Q4184","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","184.09",,,,,,,"fee schedule","184.09","986.95",
"Cellesta, 1 sq cm","Q4184","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","986.95",,,,,,,"fee schedule","184.09","986.95",
"Epifix 1 sq cm","Q4186","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","364.17",,,,,,,"fee schedule","364.17","547.79",
"Epifix 1 sq cm","Q4186","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","364.17",,,,,,,"fee schedule","364.17","547.79",
"Epifix 1 sq cm","Q4186","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","364.17",,,,,,,"fee schedule","364.17","547.79",
"Epifix 1 sq cm","Q4186","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","547.79",,,,,,,"fee schedule","364.17","547.79",
"Epicord 1 sq cm","Q4187","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","568.14",,,,,,,"fee schedule","568.14","1042.24",
"Epicord 1 sq cm","Q4187","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","568.14",,,,,,,"fee schedule","568.14","1042.24",
"Epicord 1 sq cm","Q4187","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","568.14",,,,,,,"fee schedule","568.14","1042.24",
"Epicord 1 sq cm","Q4187","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1042.24",,,,,,,"fee schedule","568.14","1042.24",
"Amnioarmor 1 sq cm","Q4188","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1134.6",,,,,,,"fee schedule","1134.6","1134.6",
"Amnioarmor 1 sq cm","Q4188","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1134.6",,,,,,,"fee schedule","1134.6","1134.6",
"Amnioarmor 1 sq cm","Q4188","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1134.6",,,,,,,"fee schedule","1134.6","1134.6",
"Artacent ac 1 sq cm","Q4190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","408.24",,,,,,,"fee schedule","408.24","408.24",
"Artacent ac 1 sq cm","Q4190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","408.24",,,,,,,"fee schedule","408.24","408.24",
"Artacent ac 1 sq cm","Q4190","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","408.24",,,,,,,"fee schedule","408.24","408.24",
"Restorigin 1 sq cm","Q4191","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2162.35",,,,,,,"fee schedule","2162.35","2162.35",
"Restorigin 1 sq cm","Q4191","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2162.35",,,,,,,"fee schedule","2162.35","2162.35",
"Restorigin 1 sq cm","Q4191","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2162.35",,,,,,,"fee schedule","2162.35","2162.35",
"Coll-e-derm 1 sq cm","Q4193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3699.02",,,,,,,"fee schedule","3699.02","3699.02",
"Coll-e-derm 1 sq cm","Q4193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3699.02",,,,,,,"fee schedule","3699.02","3699.02",
"Coll-e-derm 1 sq cm","Q4193","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3699.02",,,,,,,"fee schedule","3699.02","3699.02",
"Novachor 1 sq cm","Q4194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1654.55",,,,,,,"fee schedule","1084.91","1654.55",
"Novachor 1 sq cm","Q4194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1654.55",,,,,,,"fee schedule","1084.91","1654.55",
"Novachor 1 sq cm","Q4194","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1654.55",,,,,,,"fee schedule","1084.91","1654.55",
"Novachor 1 sq cm","Q4194","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1084.91",,,,,,,"fee schedule","1084.91","1654.55",
"Puraply 1 sq cm","Q4195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","230.4",,,,,,,"fee schedule","230.4","385.01",
"Puraply 1 sq cm","Q4195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","230.4",,,,,,,"fee schedule","230.4","385.01",
"Puraply 1 sq cm","Q4195","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","230.4",,,,,,,"fee schedule","230.4","385.01",
"Puraply 1 sq cm","Q4195","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","385.01",,,,,,,"fee schedule","230.4","385.01",
"Puraply am 1 sq cm","Q4196","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","242.57",,,,,,,"fee schedule","242.57","371.75",
"Puraply am 1 sq cm","Q4196","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","242.57",,,,,,,"fee schedule","242.57","371.75",
"Puraply am 1 sq cm","Q4196","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","242.57",,,,,,,"fee schedule","242.57","371.75",
"Puraply am 1 sq cm","Q4196","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","371.75",,,,,,,"fee schedule","242.57","371.75",
"Puraply xt 1 sq cm","Q4197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","169.13",,,,,,,"fee schedule","169.13","1016.61",
"Puraply xt 1 sq cm","Q4197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","169.13",,,,,,,"fee schedule","169.13","1016.61",
"Puraply xt 1 sq cm","Q4197","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","169.13",,,,,,,"fee schedule","169.13","1016.61",
"Puraply xt 1 sq cm","Q4197","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1016.61",,,,,,,"fee schedule","169.13","1016.61",
"Cygnus matrix, per sq cm","Q4199","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","764.57",,,,,,,"fee schedule","764.57","764.57",
"Cygnus matrix, per sq cm","Q4199","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","764.57",,,,,,,"fee schedule","764.57","764.57",
"Cygnus matrix, per sq cm","Q4199","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","764.57",,,,,,,"fee schedule","764.57","764.57",
"Matrion 1 sq cm","Q4201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","198.6",,,,,,,"fee schedule","198.6","198.6",
"Matrion 1 sq cm","Q4201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","198.6",,,,,,,"fee schedule","198.6","198.6",
"Matrion 1 sq cm","Q4201","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","198.6",,,,,,,"fee schedule","198.6","198.6",
"Derma-gide, 1 sq cm","Q4203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","690.42",,,,,,,"fee schedule","690.42","690.42",
"Derma-gide, 1 sq cm","Q4203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","690.42",,,,,,,"fee schedule","690.42","690.42",
"Derma-gide, 1 sq cm","Q4203","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","690.42",,,,,,,"fee schedule","690.42","690.42",
"Xwrap 1 sq cm","Q4204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6736.74",,,,,,,"fee schedule","6736.74","6736.74",
"Xwrap 1 sq cm","Q4204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6736.74",,,,,,,"fee schedule","6736.74","6736.74",
"Xwrap 1 sq cm","Q4204","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6736.74",,,,,,,"fee schedule","6736.74","6736.74",
"Membrane graft or wrap sq cm","Q4205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2428.73",,,,,,,"fee schedule","2428.73","2428.73",
"Membrane graft or wrap sq cm","Q4205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2428.73",,,,,,,"fee schedule","2428.73","2428.73",
"Membrane graft or wrap sq cm","Q4205","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2428.73",,,,,,,"fee schedule","2428.73","2428.73",
"Novafix per sq cm","Q4208","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","788.12",,,,,,,"fee schedule","788.12","788.12",
"Ascent, 0.5 mg","Q4213","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","175.26",,,,,,,"fee schedule","175.26","175.26",
"Woundfix biowound plus xplus","Q4217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","629.08",,,,,,,"fee schedule","629.08","849.36",
"Woundfix biowound plus xplus","Q4217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","629.08",,,,,,,"fee schedule","629.08","849.36",
"Woundfix biowound plus xplus","Q4217","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","629.08",,,,,,,"fee schedule","629.08","849.36",
"Woundfix biowound plus xplus","Q4217","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","849.36",,,,,,,"fee schedule","629.08","849.36",
"Surgicord per sq cm","Q4218","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","508.79",,,,,,,"fee schedule","508.79","508.79",
"Surgigraft dual per sq cm","Q4219","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","383.52",,,,,,,"fee schedule","383.52","383.52",
"Amniowrap2 per sq cm","Q4221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4632.2",,,,,,,"fee schedule","4632.2","4632.2",
"Amniowrap2 per sq cm","Q4221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4632.2",,,,,,,"fee schedule","4632.2","4632.2",
"Amniowrap2 per sq cm","Q4221","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4632.2",,,,,,,"fee schedule","4632.2","4632.2",
"Progenamatrix, per sq cm","Q4222","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","312.63",,,,,,,"fee schedule","312.63","312.63",
"Progenamatrix, per sq cm","Q4222","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","312.63",,,,,,,"fee schedule","312.63","312.63",
"Progenamatrix, per sq cm","Q4222","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","312.63",,,,,,,"fee schedule","312.63","312.63",
"Amniobind, per sq cm","Q4225","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3190.3",,,,,,,"fee schedule","3190.3","3190.3",
"Amniobind, per sq cm","Q4225","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3190.3",,,,,,,"fee schedule","3190.3","3190.3",
"Amniobind, per sq cm","Q4225","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3190.3",,,,,,,"fee schedule","3190.3","3190.3",
"Amniocore per sq cm","Q4227","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2742.75",,,,,,,"fee schedule","2742.75","2742.75",
"Amniocore per sq cm","Q4227","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2742.75",,,,,,,"fee schedule","2742.75","2742.75",
"Amniocore per sq cm","Q4227","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2742.75",,,,,,,"fee schedule","2742.75","2742.75",
"Cogenex amnio memb per sq cm","Q4229","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1153.57",,,,,,,"fee schedule","1153.57","1153.57",
"Cogenex amnio memb per sq cm","Q4229","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1153.57",,,,,,,"fee schedule","1153.57","1153.57",
"Cogenex amnio memb per sq cm","Q4229","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1153.57",,,,,,,"fee schedule","1153.57","1153.57",
"Corplex p, per cc","Q4231","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1509.11",,,,,,,"fee schedule","1509.11","1509.11",
"Corplex p, per cc","Q4231","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1509.11",,,,,,,"fee schedule","1509.11","1509.11",
"Corplex p, per cc","Q4231","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1509.11",,,,,,,"fee schedule","1509.11","1509.11",
"Corplex, per sq cm","Q4232","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","474.91",,,,,,,"fee schedule","474.91","474.91",
"Corplex, per sq cm","Q4232","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","474.91",,,,,,,"fee schedule","474.91","474.91",
"Corplex, per sq cm","Q4232","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","474.91",,,,,,,"fee schedule","474.91","474.91",
"Xcellerate, per sq cm","Q4234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","570.21",,,,,,,"fee schedule","570.21","570.21",
"Xcellerate, per sq cm","Q4234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","570.21",,,,,,,"fee schedule","570.21","570.21",
"Xcellerate, per sq cm","Q4234","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","570.21",,,,,,,"fee schedule","570.21","570.21",
"Amniorepair or altiply sq cm","Q4235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","218.33",,,,,,,"fee schedule","218.33","218.33",
"Amniorepair or altiply sq cm","Q4235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","218.33",,,,,,,"fee schedule","218.33","218.33",
"Amniorepair or altiply sq cm","Q4235","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","218.33",,,,,,,"fee schedule","218.33","218.33",
"Carepatch per sq cm","Q4236","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1110.24",,,,,,,"fee schedule","1110.24","1110.24",
"Carepatch per sq cm","Q4236","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1110.24",,,,,,,"fee schedule","1110.24","1110.24",
"Carepatch per sq cm","Q4236","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1110.24",,,,,,,"fee schedule","1110.24","1110.24",
"Derm-maxx, per sq cm","Q4238","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3783.48",,,,,,,"fee schedule","3783.48","3783.48",
"Derm-maxx, per sq cm","Q4238","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3783.48",,,,,,,"fee schedule","3783.48","3783.48",
"Derm-maxx, per sq cm","Q4238","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3783.48",,,,,,,"fee schedule","3783.48","3783.48",
"Amnio-maxx or lite per sq cm","Q4239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5404.83",,,,,,,"fee schedule","5404.83","5404.83",
"Amnio-maxx or lite per sq cm","Q4239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5404.83",,,,,,,"fee schedule","5404.83","5404.83",
"Amnio-maxx or lite per sq cm","Q4239","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5404.83",,,,,,,"fee schedule","5404.83","5404.83",
"Dermacyte Amn mem allo sq cm","Q4248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6433.35",,,,,,,"fee schedule","6433.35","6433.35",
"Dermacyte Amn mem allo sq cm","Q4248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6433.35",,,,,,,"fee schedule","6433.35","6433.35",
"Dermacyte Amn mem allo sq cm","Q4248","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6433.35",,,,,,,"fee schedule","6433.35","6433.35",
"AmnioAMP-MP per sq cm","Q4250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6585.21",,,,,,,"fee schedule","6585.21","6585.21",
"AmnioAMP-MP per sq cm","Q4250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6585.21",,,,,,,"fee schedule","6585.21","6585.21",
"AmnioAMP-MP per sq cm","Q4250","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6585.21",,,,,,,"fee schedule","6585.21","6585.21",
"Vendaje, per square centimet","Q4252","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","227.95",,,,,,,"fee schedule","227.95","227.95",
"Vendaje, per square centimet","Q4252","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","227.95",,,,,,,"fee schedule","227.95","227.95",
"Vendaje, per square centimet","Q4252","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","227.95",,,,,,,"fee schedule","227.95","227.95",
"Zenith amniotic membrane psc","Q4253","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","164.45",,,,,,,"fee schedule","164.45","164.45",
"Zenith amniotic membrane psc","Q4253","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","164.45",,,,,,,"fee schedule","164.45","164.45",
"Zenith amniotic membrane psc","Q4253","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","164.45",,,,,,,"fee schedule","164.45","164.45",
"Mlg complet, per sq cm","Q4256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2150.55",,,,,,,"fee schedule","2150.55","2150.55",
"Mlg complet, per sq cm","Q4256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2150.55",,,,,,,"fee schedule","2150.55","2150.55",
"Mlg complet, per sq cm","Q4256","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2150.55",,,,,,,"fee schedule","2150.55","2150.55",
"Relese, per sq cm","Q4257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1138.37",,,,,,,"fee schedule","1138.37","1138.37",
"Relese, per sq cm","Q4257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1138.37",,,,,,,"fee schedule","1138.37","1138.37",
"Relese, per sq cm","Q4257","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1138.37",,,,,,,"fee schedule","1138.37","1138.37",
"Enverse, per sq cm","Q4258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","165.17",,,,,,,"fee schedule","165.17","165.17",
"Enverse, per sq cm","Q4258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","165.17",,,,,,,"fee schedule","165.17","165.17",
"Enverse, per sq cm","Q4258","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","165.17",,,,,,,"fee schedule","165.17","165.17",
"Celera per sq cm","Q4259","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2243.1",,,,,,,"fee schedule","2243.1","2243.1",
"Celera per sq cm","Q4259","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2243.1",,,,,,,"fee schedule","2243.1","2243.1",
"Celera per sq cm","Q4259","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2243.1",,,,,,,"fee schedule","2243.1","2243.1",
"Dual layer impax, per sq cm","Q4262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","390.67",,,,,,,"fee schedule","390.67","390.67",
"Dual layer impax, per sq cm","Q4262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","390.67",,,,,,,"fee schedule","390.67","390.67",
"Dual layer impax, per sq cm","Q4262","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","390.67",,,,,,,"fee schedule","390.67","390.67",
"Surgraft tl, per sq cm","Q4263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3939.9",,,,,,,"fee schedule","3939.9","3939.9",
"Surgraft tl, per sq cm","Q4263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3939.9",,,,,,,"fee schedule","3939.9","3939.9",
"Surgraft tl, per sq cm","Q4263","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3939.9",,,,,,,"fee schedule","3939.9","3939.9",
"Cocoon membrane, per sq cm","Q4264","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1099.54",,,,,,,"fee schedule","1099.54","1099.54",
"Cocoon membrane, per sq cm","Q4264","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1099.54",,,,,,,"fee schedule","1099.54","1099.54",
"Cocoon membrane, per sq cm","Q4264","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1099.54",,,,,,,"fee schedule","1099.54","1099.54",
"Neostim tl per sq cm","Q4265","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4025.6",,,,,,,"fee schedule","4025.6","4025.6",
"Neostim tl per sq cm","Q4265","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4025.6",,,,,,,"fee schedule","4025.6","4025.6",
"Neostim tl per sq cm","Q4265","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4025.6",,,,,,,"fee schedule","4025.6","4025.6",
"Neostim per sq cm","Q4266","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2276.25",,,,,,,"fee schedule","2276.25","2276.25",
"Neostim per sq cm","Q4266","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2276.25",,,,,,,"fee schedule","2276.25","2276.25",
"Neostim per sq cm","Q4266","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2276.25",,,,,,,"fee schedule","2276.25","2276.25",
"Neostim dl per sq cm","Q4267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","631.59",,,,,,,"fee schedule","631.59","631.59",
"Neostim dl per sq cm","Q4267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","631.59",,,,,,,"fee schedule","631.59","631.59",
"Neostim dl per sq cm","Q4267","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","631.59",,,,,,,"fee schedule","631.59","631.59",
"Surgraft xt per sq cm","Q4269","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6582.6",,,,,,,"fee schedule","6582.6","6582.6",
"Surgraft xt per sq cm","Q4269","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6582.6",,,,,,,"fee schedule","6582.6","6582.6",
"Surgraft xt per sq cm","Q4269","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6582.6",,,,,,,"fee schedule","6582.6","6582.6",
"Complete sl per sq cm","Q4270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7752.84",,,,,,,"fee schedule","7752.84","7752.84",
"Complete sl per sq cm","Q4270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7752.84",,,,,,,"fee schedule","7752.84","7752.84",
"Complete sl per sq cm","Q4270","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7752.84",,,,,,,"fee schedule","7752.84","7752.84",
"Complete ft per sq cm","Q4271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3217.99",,,,,,,"fee schedule","3217.99","3217.99",
"Complete ft per sq cm","Q4271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3217.99",,,,,,,"fee schedule","3217.99","3217.99",
"Complete ft per sq cm","Q4271","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3217.99",,,,,,,"fee schedule","3217.99","3217.99",
"Esano ac, per sq cm","Q4274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4228.07",,,,,,,"fee schedule","4228.07","4228.07",
"Esano ac, per sq cm","Q4274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4228.07",,,,,,,"fee schedule","4228.07","4228.07",
"Esano ac, per sq cm","Q4274","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4228.07",,,,,,,"fee schedule","4228.07","4228.07",
"Esano aca, per sq cm","Q4275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6155.95",,,,,,,"fee schedule","6155.95","6155.95",
"Esano aca, per sq cm","Q4275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6155.95",,,,,,,"fee schedule","6155.95","6155.95",
"Esano aca, per sq cm","Q4275","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6155.95",,,,,,,"fee schedule","6155.95","6155.95",
"Orion, per sq cm","Q4276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1067.99",,,,,,,"fee schedule","1067.99","1067.99",
"Orion, per sq cm","Q4276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1067.99",,,,,,,"fee schedule","1067.99","1067.99",
"Orion, per sq cm","Q4276","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1067.99",,,,,,,"fee schedule","1067.99","1067.99",
"Epieffect, per sq cm","Q4278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","565.91",,,,,,,"fee schedule","565.91","565.91",
"Epieffect, per sq cm","Q4278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","565.91",,,,,,,"fee schedule","565.91","565.91",
"Epieffect, per sq cm","Q4278","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","565.91",,,,,,,"fee schedule","565.91","565.91",
"Vendaje ac, per sq cm","Q4279","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5485.5",,,,,,,"fee schedule","5485.5","5485.5",
"Vendaje ac, per sq cm","Q4279","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5485.5",,,,,,,"fee schedule","5485.5","5485.5",
"Vendaje ac, per sq cm","Q4279","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5485.5",,,,,,,"fee schedule","5485.5","5485.5",
"Xcell amnio matrix per sq cm","Q4280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7465.91",,,,,,,"fee schedule","7465.91","7465.91",
"Xcell amnio matrix per sq cm","Q4280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7465.91",,,,,,,"fee schedule","7465.91","7465.91",
"Xcell amnio matrix per sq cm","Q4280","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7465.91",,,,,,,"fee schedule","7465.91","7465.91",
"Barrera slor dl per sq cm","Q4281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1288.68",,,,,,,"fee schedule","1288.68","1288.68",
"Barrera slor dl per sq cm","Q4281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1288.68",,,,,,,"fee schedule","1288.68","1288.68",
"Barrera slor dl per sq cm","Q4281","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1288.68",,,,,,,"fee schedule","1288.68","1288.68",
"Cygnus dual per sq cm","Q4282","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1120.82",,,,,,,"fee schedule","1120.82","1120.82",
"Cygnus dual per sq cm","Q4282","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1120.82",,,,,,,"fee schedule","1120.82","1120.82",
"Cygnus dual per sq cm","Q4282","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1120.82",,,,,,,"fee schedule","1120.82","1120.82",
"Biovance tri or 3l, sq cm","Q4283","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1266.48",,,,,,,"fee schedule","1266.48","1266.48",
"Biovance tri or 3l, sq cm","Q4283","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1266.48",,,,,,,"fee schedule","1266.48","1266.48",
"Biovance tri or 3l, sq cm","Q4283","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1266.48",,,,,,,"fee schedule","1266.48","1266.48",
"Revoshield+ amnio, per sq cm","Q4289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3685.13",,,,,,,"fee schedule","3685.13","3685.13",
"Revoshield+ amnio, per sq cm","Q4289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3685.13",,,,,,,"fee schedule","3685.13","3685.13",
"Revoshield+ amnio, per sq cm","Q4289","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3685.13",,,,,,,"fee schedule","3685.13","3685.13",
"Membrane wrap hydr per sq cm","Q4290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4234.3",,,,,,,"fee schedule","4234.3","4234.3",
"Membrane wrap hydr per sq cm","Q4290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4234.3",,,,,,,"fee schedule","4234.3","4234.3",
"Membrane wrap hydr per sq cm","Q4290","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4234.3",,,,,,,"fee schedule","4234.3","4234.3",
"Acesso dl, per sq cm","Q4293","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3644.81",,,,,,,"fee schedule","3644.81","3644.81",
"Acesso dl, per sq cm","Q4293","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3644.81",,,,,,,"fee schedule","3644.81","3644.81",
"Acesso dl, per sq cm","Q4293","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3644.81",,,,,,,"fee schedule","3644.81","3644.81",
"Amnio quad-core, per sq cm","Q4294","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6095",,,,,,,"fee schedule","6095","6095",
"Amnio quad-core, per sq cm","Q4294","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6095",,,,,,,"fee schedule","6095","6095",
"Amnio quad-core, per sq cm","Q4294","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6095",,,,,,,"fee schedule","6095","6095",
"Amnio tri-core, per sq cm","Q4295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5363.6",,,,,,,"fee schedule","5363.6","5363.6",
"Amnio tri-core, per sq cm","Q4295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5363.6",,,,,,,"fee schedule","5363.6","5363.6",
"Amnio tri-core, per sq cm","Q4295","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5363.6",,,,,,,"fee schedule","5363.6","5363.6",
"Rebound matrix, per sq cm","Q4296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3395.1",,,,,,,"fee schedule","3395.1","3395.1",
"Rebound matrix, per sq cm","Q4296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3395.1",,,,,,,"fee schedule","3395.1","3395.1",
"Rebound matrix, per sq cm","Q4296","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3395.1",,,,,,,"fee schedule","3395.1","3395.1",
"Emerge matrix, per sq cm","Q4297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4020.91",,,,,,,"fee schedule","4020.91","4020.91",
"Emerge matrix, per sq cm","Q4297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4020.91",,,,,,,"fee schedule","4020.91","4020.91",
"Emerge matrix, per sq cm","Q4297","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4020.91",,,,,,,"fee schedule","4020.91","4020.91",
"Amnicore pro, per sq cm","Q4298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5241.7",,,,,,,"fee schedule","5241.7","5241.7",
"Amnicore pro, per sq cm","Q4298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5241.7",,,,,,,"fee schedule","5241.7","5241.7",
"Amnicore pro, per sq cm","Q4298","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5241.7",,,,,,,"fee schedule","5241.7","5241.7",
"Amnicore pro+, per sq cm","Q4299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5973.1",,,,,,,"fee schedule","5973.1","5973.1",
"Amnicore pro+, per sq cm","Q4299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5973.1",,,,,,,"fee schedule","5973.1","5973.1",
"Amnicore pro+, per sq cm","Q4299","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5973.1",,,,,,,"fee schedule","5973.1","5973.1",
"Acesso tl, per sq cm","Q4300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4863.81",,,,,,,"fee schedule","4863.81","4863.81",
"Acesso tl, per sq cm","Q4300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4863.81",,,,,,,"fee schedule","4863.81","4863.81",
"Acesso tl, per sq cm","Q4300","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4863.81",,,,,,,"fee schedule","4863.81","4863.81",
"Activate matrix, per sq cm","Q4301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4362.55",,,,,,,"fee schedule","4362.55","4362.55",
"Activate matrix, per sq cm","Q4301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4362.55",,,,,,,"fee schedule","4362.55","4362.55",
"Activate matrix, per sq cm","Q4301","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4362.55",,,,,,,"fee schedule","4362.55","4362.55",
"Complete aca, per sq cm","Q4302","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4620.01",,,,,,,"fee schedule","4620.01","4620.01",
"Complete aca, per sq cm","Q4302","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4620.01",,,,,,,"fee schedule","4620.01","4620.01",
"Complete aca, per sq cm","Q4302","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4620.01",,,,,,,"fee schedule","4620.01","4620.01",
"Complete aa, per sq cm","Q4303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7814.02",,,,,,,"fee schedule","7814.02","7814.02",
"Complete aa, per sq cm","Q4303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7814.02",,,,,,,"fee schedule","7814.02","7814.02",
"Complete aa, per sq cm","Q4303","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7814.02",,,,,,,"fee schedule","7814.02","7814.02",
"Grafix plus, per sq cm","Q4304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1732.96",,,,,,,"fee schedule","1732.96","1732.96",
"Grafix plus, per sq cm","Q4304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1732.96",,,,,,,"fee schedule","1732.96","1732.96",
"Grafix plus, per sq cm","Q4304","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1732.96",,,,,,,"fee schedule","1732.96","1732.96",
"Via matrix, per sq cm","Q4309","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3045.12",,,,,,,"fee schedule","3045.12","3045.12",
"Via matrix, per sq cm","Q4309","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3045.12",,,,,,,"fee schedule","3045.12","3045.12",
"Via matrix, per sq cm","Q4309","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3045.12",,,,,,,"fee schedule","3045.12","3045.12",
"Procenta, per 100 mg","Q4310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","5090.22",,,,,,,"fee schedule","5090.22","5090.22",
"Procenta, per 100 mg","Q4310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","5090.22",,,,,,,"fee schedule","5090.22","5090.22",
"Procenta, per 100 mg","Q4310","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","5090.22",,,,,,,"fee schedule","5090.22","5090.22",
"Dermabind fm, per sq cm","Q4313","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","7675.63",,,,,,,"fee schedule","7675.63","7675.63",
"Dermabind fm, per sq cm","Q4313","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","7675.63",,,,,,,"fee schedule","7675.63","7675.63",
"Dermabind fm, per sq cm","Q4313","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","7675.63",,,,,,,"fee schedule","7675.63","7675.63",
"Sanograft, per sq cm","Q4319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6095",,,,,,,"fee schedule","6095","6095",
"Sanograft, per sq cm","Q4319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6095",,,,,,,"fee schedule","6095","6095",
"Sanograft, per sq cm","Q4319","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6095",,,,,,,"fee schedule","6095","6095",
"Caregraft, per sq cm","Q4322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4266.5",,,,,,,"fee schedule","4266.5","4266.5",
"Caregraft, per sq cm","Q4322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4266.5",,,,,,,"fee schedule","4266.5","4266.5",
"Caregraft, per sq cm","Q4322","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4266.5",,,,,,,"fee schedule","4266.5","4266.5",
"Alloply, per sq cm","Q4323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3778.9",,,,,,,"fee schedule","3778.9","3778.9",
"Alloply, per sq cm","Q4323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3778.9",,,,,,,"fee schedule","3778.9","3778.9",
"Alloply, per sq cm","Q4323","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3778.9",,,,,,,"fee schedule","3778.9","3778.9",
"Acapatch, per sq cm","Q4325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4754.1",,,,,,,"fee schedule","4754.1","4754.1",
"Acapatch, per sq cm","Q4325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4754.1",,,,,,,"fee schedule","4754.1","4754.1",
"Acapatch, per sq cm","Q4325","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4754.1",,,,,,,"fee schedule","4754.1","4754.1",
"Most, per sq cm","Q4328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","8533",,,,,,,"fee schedule","8533","8533",
"Most, per sq cm","Q4328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","8533",,,,,,,"fee schedule","8533","8533",
"Most, per sq cm","Q4328","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","8533",,,,,,,"fee schedule","8533","8533",
"Axolotl dualgraft, per sq cm","Q4332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","3901.18",,,,,,,"fee schedule","3901.18","3901.18",
"Axolotl dualgraft, per sq cm","Q4332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","3901.18",,,,,,,"fee schedule","3901.18","3901.18",
"Axolotl dualgraft, per sq cm","Q4332","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","3901.18",,,,,,,"fee schedule","3901.18","3901.18",
"Dermacyte ac matrx per sq cm","Q4343","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","6789.83",,,,,,,"fee schedule","6789.83","6789.83",
"Dermacyte ac matrx per sq cm","Q4343","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","6789.83",,,,,,,"fee schedule","6789.83","6789.83",
"Dermacyte ac matrx per sq cm","Q4343","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","6789.83",,,,,,,"fee schedule","6789.83","6789.83",
"Inj filgrastim gcsf biosimil","Q5101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.77",,,,,,,"fee schedule","0.77","1.67",
"Inj filgrastim gcsf biosimil","Q5101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.77",,,,,,,"fee schedule","0.77","1.67",
"Inj filgrastim gcsf biosimil","Q5101","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.77",,,,,,,"fee schedule","0.77","1.67",
"Inj filgrastim gcsf biosimil","Q5101","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.67",,,,,,,"fee schedule","0.77","1.67",
"Injection, inflectra","Q5103","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","131.97",,,,,,,"fee schedule","36.6","161.98",
"Injection, inflectra","Q5103","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","133.29",,,,,,,"fee schedule","36.6","161.98",
"Injection, inflectra","Q5103","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","36.6",,,,,,,"fee schedule","36.6","161.98",
"Injection, inflectra","Q5103","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","36.6",,,,,,,"fee schedule","36.6","161.98",
"Injection, inflectra","Q5103","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","36.6",,,,,,,"fee schedule","36.6","161.98",
"Injection, inflectra","Q5103","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","161.98",,,,,,,"fee schedule","36.6","161.98",
"Injection, renflexis","Q5104","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","64.04",,,,,,,"fee schedule","64.04","169",
"Injection, renflexis","Q5104","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","129.01",,,,,,,"fee schedule","64.04","169",
"Injection, renflexis","Q5104","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","130.29",,,,,,,"fee schedule","64.04","169",
"Injection, renflexis","Q5104","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","64.04",,,,,,,"fee schedule","64.04","169",
"Injection, renflexis","Q5104","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","64.04",,,,,,,"fee schedule","64.04","169",
"Injection, renflexis","Q5104","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","169",,,,,,,"fee schedule","64.04","169",
"Inj Retacrit esrd on dialysi","Q5105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1.63",,,,,,,"fee schedule","1.63","3.12",
"Inj Retacrit esrd on dialysi","Q5105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1.63",,,,,,,"fee schedule","1.63","3.12",
"Inj Retacrit esrd on dialysi","Q5105","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1.63",,,,,,,"fee schedule","1.63","3.12",
"Inj Retacrit esrd on dialysi","Q5105","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","3.12",,,,,,,"fee schedule","1.63","3.12",
"Inj Retacrit non-esrd use","Q5106","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","26.2",,,,,,,"fee schedule","16.26","31.23",
"Inj Retacrit non-esrd use","Q5106","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","26.47",,,,,,,"fee schedule","16.26","31.23",
"Inj Retacrit non-esrd use","Q5106","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","16.26",,,,,,,"fee schedule","16.26","31.23",
"Inj Retacrit non-esrd use","Q5106","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","16.26",,,,,,,"fee schedule","16.26","31.23",
"Inj Retacrit non-esrd use","Q5106","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","16.26",,,,,,,"fee schedule","16.26","31.23",
"Inj Retacrit non-esrd use","Q5106","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","31.23",,,,,,,"fee schedule","16.26","31.23",
"Inj mvasi 10 mg","Q5107","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","68.6",,,,,,,"fee schedule","68.6","212.45",
"Inj mvasi 10 mg","Q5107","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","68.6",,,,,,,"fee schedule","68.6","212.45",
"Inj mvasi 10 mg","Q5107","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","68.6",,,,,,,"fee schedule","68.6","212.45",
"Inj mvasi 10 mg","Q5107","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","212.45",,,,,,,"fee schedule","68.6","212.45",
"Injection, fulphila","Q5108","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","259.66",,,,,,,"fee schedule","259.66","1042.61",
"Injection, fulphila","Q5108","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","259.66",,,,,,,"fee schedule","259.66","1042.61",
"Injection, fulphila","Q5108","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","259.66",,,,,,,"fee schedule","259.66","1042.61",
"Injection, fulphila","Q5108","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1042.61",,,,,,,"fee schedule","259.66","1042.61",
"Nivestym","Q5110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.66",,,,,,,"fee schedule","0.66","2.15",
"Nivestym","Q5110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.66",,,,,,,"fee schedule","0.66","2.15",
"Nivestym","Q5110","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.66",,,,,,,"fee schedule","0.66","2.15",
"Nivestym","Q5110","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.15",,,,,,,"fee schedule","0.66","2.15",
"Injection, udenyca 0.5 mg","Q5111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","376.29",,,,,,,"fee schedule","376.29","1091.18",
"Injection, udenyca 0.5 mg","Q5111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","376.29",,,,,,,"fee schedule","376.29","1091.18",
"Injection, udenyca 0.5 mg","Q5111","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","376.29",,,,,,,"fee schedule","376.29","1091.18",
"Injection, udenyca 0.5 mg","Q5111","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1091.18",,,,,,,"fee schedule","376.29","1091.18",
"Inj ontruzant 10 mg","Q5112","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","270.23",,,,,,,"fee schedule","66.1","272.93",
"Inj ontruzant 10 mg","Q5112","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","272.93",,,,,,,"fee schedule","66.1","272.93",
"Inj ontruzant 10 mg","Q5112","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","66.1",,,,,,,"fee schedule","66.1","272.93",
"Inj ontruzant 10 mg","Q5112","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","66.1",,,,,,,"fee schedule","66.1","272.93",
"Inj ontruzant 10 mg","Q5112","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","66.1",,,,,,,"fee schedule","66.1","272.93",
"Inj herzuma 10 mg","Q5113","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","267.53",,,,,,,"fee schedule","169.98","267.53",
"Inj herzuma 10 mg","Q5113","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","169.98",,,,,,,"fee schedule","169.98","267.53",
"Inj herzuma 10 mg","Q5113","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","169.98",,,,,,,"fee schedule","169.98","267.53",
"Inj herzuma 10 mg","Q5113","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","264.88",,,,,,,"fee schedule","169.98","267.53",
"Inj herzuma 10 mg","Q5113","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","169.98",,,,,,,"fee schedule","169.98","267.53",
"Inj  ogivri 10 mg","Q5114","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","226.17",,,,,,,"fee schedule","107.68","307.42",
"Inj  ogivri 10 mg","Q5114","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","223.94",,,,,,,"fee schedule","107.68","307.42",
"Inj  ogivri 10 mg","Q5114","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","107.68",,,,,,,"fee schedule","107.68","307.42",
"Inj  ogivri 10 mg","Q5114","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","107.68",,,,,,,"fee schedule","107.68","307.42",
"Inj  ogivri 10 mg","Q5114","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","107.68",,,,,,,"fee schedule","107.68","307.42",
"Inj  ogivri 10 mg","Q5114","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","307.42",,,,,,,"fee schedule","107.68","307.42",
"Inj truxima 10 mg","Q5115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","209.95",,,,,,,"fee schedule","79.95","295.27",
"Inj truxima 10 mg","Q5115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","212.06",,,,,,,"fee schedule","79.95","295.27",
"Inj truxima 10 mg","Q5115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","79.95",,,,,,,"fee schedule","79.95","295.27",
"Inj truxima 10 mg","Q5115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","79.95",,,,,,,"fee schedule","79.95","295.27",
"Inj truxima 10 mg","Q5115","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","79.95",,,,,,,"fee schedule","79.95","295.27",
"Inj truxima 10 mg","Q5115","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","295.27",,,,,,,"fee schedule","79.95","295.27",
"Inj., trazimera, 10 mg","Q5116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","229.14",,,,,,,"fee schedule","57.34","281.95",
"Inj., trazimera, 10 mg","Q5116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","226.88",,,,,,,"fee schedule","57.34","281.95",
"Inj., trazimera, 10 mg","Q5116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","57.34",,,,,,,"fee schedule","57.34","281.95",
"Inj., trazimera, 10 mg","Q5116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","57.34",,,,,,,"fee schedule","57.34","281.95",
"Inj., trazimera, 10 mg","Q5116","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","57.34",,,,,,,"fee schedule","57.34","281.95",
"Inj., trazimera, 10 mg","Q5116","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","281.95",,,,,,,"fee schedule","57.34","281.95",
"Inj., kanjinti, 10 mg","Q5117","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","64.18",,,,,,,"fee schedule","64.18","277.64",
"Inj., kanjinti, 10 mg","Q5117","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","64.18",,,,,,,"fee schedule","64.18","277.64",
"Inj., kanjinti, 10 mg","Q5117","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","64.18",,,,,,,"fee schedule","64.18","277.64",
"Inj., kanjinti, 10 mg","Q5117","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","277.64",,,,,,,"fee schedule","64.18","277.64",
"Inj., zirabev, 10 mg","Q5118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","61.97",,,,,,,"fee schedule","61.97","214.21",
"Inj., zirabev, 10 mg","Q5118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","61.97",,,,,,,"fee schedule","61.97","214.21",
"Inj., zirabev, 10 mg","Q5118","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","61.97",,,,,,,"fee schedule","61.97","214.21",
"Inj., zirabev, 10 mg","Q5118","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","214.21",,,,,,,"fee schedule","61.97","214.21",
"Inj ruxience, 10 mg","Q5119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","HMO/PPO","208.41",,,,,,,"fee schedule","57.37","208.41",
"Inj ruxience, 10 mg","Q5119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Anthem","Individual","206.35",,,,,,,"fee schedule","57.37","208.41",
"Inj ruxience, 10 mg","Q5119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","57.37",,,,,,,"fee schedule","57.37","208.41",
"Inj ruxience, 10 mg","Q5119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","57.37",,,,,,,"fee schedule","57.37","208.41",
"Inj ruxience, 10 mg","Q5119","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","57.37",,,,,,,"fee schedule","57.37","208.41",
"Inj ruxience, 10 mg","Q5119","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","197.74",,,,,,,"fee schedule","57.37","208.41",
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","56.84",,,,,,,"fee schedule","56.84","1142.35",
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","56.84",,,,,,,"fee schedule","56.84","1142.35",
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","56.84",,,,,,,"fee schedule","56.84","1142.35",
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1142.35",,,,,,,"fee schedule","56.84","1142.35",
"Inj. avsola, 10 mg","Q5121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","45.42",,,,,,,"fee schedule","45.42","45.42",
"Inj. avsola, 10 mg","Q5121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","45.42",,,,,,,"fee schedule","45.42","45.42",
"Inj. avsola, 10 mg","Q5121","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","45.42",,,,,,,"fee schedule","45.42","45.42",
"Inj, nyvepria","Q5122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","308.78",,,,,,,"fee schedule","308.78","308.78",
"Inj, nyvepria","Q5122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","308.78",,,,,,,"fee schedule","308.78","308.78",
"Inj, nyvepria","Q5122","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","308.78",,,,,,,"fee schedule","308.78","308.78",
"Inj. riabni, 10 mg","Q5123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","76.1",,,,,,,"fee schedule","76.1","76.1",
"Inj. riabni, 10 mg","Q5123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","76.1",,,,,,,"fee schedule","76.1","76.1",
"Inj. riabni, 10 mg","Q5123","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","76.1",,,,,,,"fee schedule","76.1","76.1",
"Inj. byooviz, 0.1 mg","Q5124","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","196.81",,,,,,,"fee schedule","196.81","196.81",
"Inj. byooviz, 0.1 mg","Q5124","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","196.81",,,,,,,"fee schedule","196.81","196.81",
"Inj. byooviz, 0.1 mg","Q5124","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","196.81",,,,,,,"fee schedule","196.81","196.81",
"Inj, releuko 1 mcg","Q5125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.98",,,,,,,"fee schedule","0.98","0.98",
"Inj, releuko 1 mcg","Q5125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.98",,,,,,,"fee schedule","0.98","0.98",
"Inj, releuko 1 mcg","Q5125","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.98",,,,,,,"fee schedule","0.98","0.98",
"Inj alymsys 10 mg","Q5126","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","105.92",,,,,,,"fee schedule","105.92","105.92",
"Inj alymsys 10 mg","Q5126","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","105.92",,,,,,,"fee schedule","105.92","105.92",
"Inj alymsys 10 mg","Q5126","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","105.92",,,,,,,"fee schedule","105.92","105.92",
"Inj, stimufend, 0.5 mg","Q5127","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","577.86",,,,,,,"fee schedule","577.86","577.86",
"Inj, stimufend, 0.5 mg","Q5127","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","577.86",,,,,,,"fee schedule","577.86","577.86",
"Inj, stimufend, 0.5 mg","Q5127","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","577.86",,,,,,,"fee schedule","577.86","577.86",
"Inj, cimerli, 0.1 mg","Q5128","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","337.55",,,,,,,"fee schedule","337.55","337.55",
"Inj, cimerli, 0.1 mg","Q5128","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","337.55",,,,,,,"fee schedule","337.55","337.55",
"Inj, cimerli, 0.1 mg","Q5128","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","337.55",,,,,,,"fee schedule","337.55","337.55",
"Inj, vegzelma, 10 mg","Q5129","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","110.58",,,,,,,"fee schedule","110.58","110.58",
"Inj, vegzelma, 10 mg","Q5129","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","110.58",,,,,,,"fee schedule","110.58","110.58",
"Inj, vegzelma, 10 mg","Q5129","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","110.58",,,,,,,"fee schedule","110.58","110.58",
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","377.55",,,,,,,"fee schedule","377.55","377.55",
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","377.55",,,,,,,"fee schedule","377.55","377.55",
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","377.55",,,,,,,"fee schedule","377.55","377.55",
"Inj, tofidence, 1 mg","Q5133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","13.73",,,,,,,"fee schedule","13.73","13.73",
"Inj, tofidence, 1 mg","Q5133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","13.73",,,,,,,"fee schedule","13.73","13.73",
"Inj, tofidence, 1 mg","Q5133","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","13.73",,,,,,,"fee schedule","13.73","13.73",
"Inj, tyenne, 1 mg","Q5135","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","9.35",,,,,,,"fee schedule","9.35","9.35",
"Inj, tyenne, 1 mg","Q5135","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","9.35",,,,,,,"fee schedule","9.35","9.35",
"Inj, tyenne, 1 mg","Q5135","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","9.35",,,,,,,"fee schedule","9.35","9.35",
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","1830.48",,,,,,,"fee schedule","1830.48","1830.48",
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","1830.48",,,,,,,"fee schedule","1830.48","1830.48",
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","1830.48",,,,,,,"fee schedule","1830.48","1830.48",
"Inj sulf hexa lipid microsph","Q9950","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","43.06",,,,,,,"fee schedule","43.06","64.63",
"Inj sulf hexa lipid microsph","Q9950","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","43.06",,,,,,,"fee schedule","43.06","64.63",
"Inj sulf hexa lipid microsph","Q9950","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","43.06",,,,,,,"fee schedule","43.06","64.63",
"Inj sulf hexa lipid microsph","Q9950","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","64.63",,,,,,,"fee schedule","43.06","64.63",
"Inj octafluoropropane mic,ml","Q9956","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","96.33",,,,,,,"fee schedule","96.33","109.76",
"Inj octafluoropropane mic,ml","Q9956","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","96.33",,,,,,,"fee schedule","96.33","109.76",
"Inj octafluoropropane mic,ml","Q9956","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","96.33",,,,,,,"fee schedule","96.33","109.76",
"Inj octafluoropropane mic,ml","Q9956","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","109.76",,,,,,,"fee schedule","96.33","109.76",
"Inj perflutren lip micros,ml","Q9957","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","96.33",,,,,,,"fee schedule","96.33","164.6",
"Inj perflutren lip micros,ml","Q9957","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","96.33",,,,,,,"fee schedule","96.33","164.6",
"Inj perflutren lip micros,ml","Q9957","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","96.33",,,,,,,"fee schedule","96.33","164.6",
"Inj perflutren lip micros,ml","Q9957","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","164.6",,,,,,,"fee schedule","96.33","164.6",
"HOCM <=149 mg/ml iodine, 1ml","Q9958","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.17",,,,,,,"fee schedule","0.17","0.27",
"HOCM <=149 mg/ml iodine, 1ml","Q9958","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.17",,,,,,,"fee schedule","0.17","0.27",
"HOCM <=149 mg/ml iodine, 1ml","Q9958","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.27",,,,,,,"fee schedule","0.17","0.27",
"HOCM <=149 mg/ml iodine, 1ml","Q9958","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.17",,,,,,,"fee schedule","0.17","0.27",
"HOCM 200-249mg/ml iodine,1ml","Q9960","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.69",,,,,,,"fee schedule","0.69","0.69",
"HOCM 250-299mg/ml iodine,1ml","Q9961","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.66",,,,,,,"fee schedule","0.66","0.84",
"HOCM 250-299mg/ml iodine,1ml","Q9961","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.66",,,,,,,"fee schedule","0.66","0.84",
"HOCM 250-299mg/ml iodine,1ml","Q9961","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.84",,,,,,,"fee schedule","0.66","0.84",
"HOCM 250-299mg/ml iodine,1ml","Q9961","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.66",,,,,,,"fee schedule","0.66","0.84",
"HOCM 350-399mg/ml iodine,1ml","Q9963","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.5",,,,,,,"fee schedule","0.5","0.65",
"HOCM 350-399mg/ml iodine,1ml","Q9963","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.65",,,,,,,"fee schedule","0.5","0.65",
"HOCM 350-399mg/ml iodine,1ml","Q9963","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.5",,,,,,,"fee schedule","0.5","0.65",
"HOCM 350-399mg/ml iodine,1ml","Q9963","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.5",,,,,,,"fee schedule","0.5","0.65",
"LOCM 100-199mg/ml iodine,1ml","Q9965","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","2.15",,,,,,,"fee schedule","2.15","2.95",
"LOCM 100-199mg/ml iodine,1ml","Q9965","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","2.15",,,,,,,"fee schedule","2.15","2.95",
"LOCM 100-199mg/ml iodine,1ml","Q9965","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","2.15",,,,,,,"fee schedule","2.15","2.95",
"LOCM 100-199mg/ml iodine,1ml","Q9965","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","2.95",,,,,,,"fee schedule","2.15","2.95",
"LOCM 200-299mg/ml iodine,1ml","Q9966","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.94",,,,,,,"fee schedule","0.94","1.12",
"LOCM 200-299mg/ml iodine,1ml","Q9966","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.94",,,,,,,"fee schedule","0.94","1.12",
"LOCM 200-299mg/ml iodine,1ml","Q9966","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.94",,,,,,,"fee schedule","0.94","1.12",
"LOCM 200-299mg/ml iodine,1ml","Q9966","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","1.12",,,,,,,"fee schedule","0.94","1.12",
"LOCM 300-399mg/ml iodine,1ml","Q9967","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","0.4",,,,,,,"fee schedule","0.33","0.4",
"LOCM 300-399mg/ml iodine,1ml","Q9967","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","0.33",,,,,,,"fee schedule","0.33","0.4",
"LOCM 300-399mg/ml iodine,1ml","Q9967","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","0.33",,,,,,,"fee schedule","0.33","0.4",
"LOCM 300-399mg/ml iodine,1ml","Q9967","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","0.33",,,,,,,"fee schedule","0.33","0.4",
"Visualization adjunct","Q9968","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","21.99",,,,,,,"fee schedule","21.99","21.99",
"Non-HEU TC-99M add-on/dose","Q9969","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","33.9",,,,,,,"fee schedule","33.9","33.9",
"flutemetamol f18 diagnostic","Q9982","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","11859.51",,,,,,,"fee schedule","11859.51","11859.51",
"florbetaben f18 diagnostic","Q9983","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","10062.61",,,,,,,"fee schedule","10062.61","10062.61",
"Buprenorph xr 100 mg or less","Q9991","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4428.03",,,,,,,"fee schedule","4428.03","5648.7",
"Buprenorph xr 100 mg or less","Q9991","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4428.03",,,,,,,"fee schedule","4428.03","5648.7",
"Buprenorph xr 100 mg or less","Q9991","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4428.03",,,,,,,"fee schedule","4428.03","5648.7",
"Buprenorph xr 100 mg or less","Q9991","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5648.7",,,,,,,"fee schedule","4428.03","5648.7",
"Buprenorphine xr over 100 mg","Q9992","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","SFHSS","4428.03",,,,,,,"fee schedule","4428.03","5648.7",
"Buprenorphine xr over 100 mg","Q9992","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","Individual","4428.03",,,,,,,"fee schedule","4428.03","5648.7",
"Buprenorphine xr over 100 mg","Q9992","HCPCS",,,,,,,"facility","outpatient",,,,,,"Blue Shield","HMO/PPO","4428.03",,,,,,,"fee schedule","4428.03","5648.7",
"Buprenorphine xr over 100 mg","Q9992","HCPCS",,,,,,,"facility","outpatient",,,,,,"United","HMO / PPO","5648.7",,,,,,,"fee schedule","4428.03","5648.7",
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","277886.5","277886.5","277886.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","95820","95820","95820","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","337556.9","337556.9","337556.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","4573.56","4573.56","4573.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","483610.55","483610.55","483610.55","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","8258.57","8258.57","8258.57","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","50971.74","50971.74","50971.74","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","412000","412000","412000","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","374487","374487","374487","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","114030.12","114030.12","114030.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","385336",,,,,,,"fee schedule","354431","385336",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","373781",,,,,,,"fee schedule","354431","385336",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","354431",,,,,,,"fee schedule","354431","385336",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","385336",,,,,,,"fee schedule","354431","385336",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","287205",,,,,,,"fee schedule","287205","306453",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","306453",,,,,,,"fee schedule","287205","306453",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","290587",,,,,,,"fee schedule","287205","306453",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","287205",,,,,,,"fee schedule","287205","306453",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","354510",,,,,,,"fee schedule","354431","373781",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","373781",,,,,,,"fee schedule","354431","373781",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","354431",,,,,,,"fee schedule","354431","373781",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","354510",,,,,,,"fee schedule","354431","373781",
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","250662",,,,,,,"fee schedule","230569","250662",
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","243357",,,,,,,"fee schedule","230569","250662",
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","250662",,,,,,,"fee schedule","230569","250662",
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","230569",,,,,,,"fee schedule","230569","250662",
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","230956","230956","230956","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","224758",,,,,,,"fee schedule","224758","240030",
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","240030",,,,,,,"fee schedule","224758","240030",
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","227416",,,,,,,"fee schedule","224758","240030",
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","224758",,,,,,,"fee schedule","224758","240030",
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","140289",,,,,,,"fee schedule","140289","170545",
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","149720",,,,,,,"fee schedule","140289","170545",
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","170545",,,,,,,"fee schedule","140289","170545",
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","140289",,,,,,,"fee schedule","140289","170545",
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","109371","109371","109371","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","109516",,,,,,,"fee schedule","100648","109516",
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","106164",,,,,,,"fee schedule","100648","109516",
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","100648",,,,,,,"fee schedule","100648","109516",
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","109516",,,,,,,"fee schedule","100648","109516",
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","96317","96317","96317","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","90868","90868","90868","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","44023.86","44023.86","44023.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","100969","100969","100969","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","95970",,,,,,,"fee schedule","85891","102235",
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","85891",,,,,,,"fee schedule","85891","102235",
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","95970",,,,,,,"fee schedule","85891","102235",
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","102235",,,,,,,"fee schedule","85891","102235",
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","173943",,,,,,,"fee schedule","160167","173943",
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","168928",,,,,,,"fee schedule","160167","173943",
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","160167",,,,,,,"fee schedule","160167","173943",
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","173943",,,,,,,"fee schedule","160167","173943",
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","94127",,,,,,,"fee schedule","94127","100553",
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","100553",,,,,,,"fee schedule","94127","100553",
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","95337",,,,,,,"fee schedule","94127","100553",
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","94127",,,,,,,"fee schedule","94127","100553",
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","82249",,,,,,,"fee schedule","75875","82249",
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","80032",,,,,,,"fee schedule","75875","82249",
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","75875",,,,,,,"fee schedule","75875","82249",
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","82249",,,,,,,"fee schedule","75875","82249",
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","124749",,,,,,,"fee schedule","114623","124749",
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","120860",,,,,,,"fee schedule","114623","124749",
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","124749",,,,,,,"fee schedule","114623","124749",
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","114623",,,,,,,"fee schedule","114623","124749",
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","108726",,,,,,,"fee schedule","108726","115869",
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","115869",,,,,,,"fee schedule","108726","115869",
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","109889",,,,,,,"fee schedule","108726","115869",
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","108726",,,,,,,"fee schedule","108726","115869",
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","67218",,,,,,,"fee schedule","61883","67218",
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","65332",,,,,,,"fee schedule","61883","67218",
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","61883",,,,,,,"fee schedule","61883","67218",
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","67218",,,,,,,"fee schedule","61883","67218",
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","51727.19","51727.19","51727.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","27538.28","27538.28","27538.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","31631.12","31631.12","31631.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","92643",,,,,,,"fee schedule","92267","99068",
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","99068",,,,,,,"fee schedule","92267","99068",
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","92643",,,,,,,"fee schedule","92267","99068",
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","92267",,,,,,,"fee schedule","92267","99068",
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","68986",,,,,,,"fee schedule","68986","73769",
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","73769",,,,,,,"fee schedule","68986","73769",
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","69839",,,,,,,"fee schedule","68986","73769",
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","68986",,,,,,,"fee schedule","68986","73769",
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22364.77","22364.77","22364.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","48331",,,,,,,"fee schedule","48331","51807",
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","51807",,,,,,,"fee schedule","48331","51807",
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","49085",,,,,,,"fee schedule","48331","51807",
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","48331",,,,,,,"fee schedule","48331","51807",
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","203911",,,,,,,"fee schedule","177687","203911",
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","177687",,,,,,,"fee schedule","177687","203911",
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","203911",,,,,,,"fee schedule","177687","203911",
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","100452",,,,,,,"fee schedule","100452","107122",
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","107122",,,,,,,"fee schedule","100452","107122",
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","101529",,,,,,,"fee schedule","100452","107122",
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","100452",,,,,,,"fee schedule","100452","107122",
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","74105",,,,,,,"fee schedule","74105","79097",
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","79097",,,,,,,"fee schedule","74105","79097",
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","75069",,,,,,,"fee schedule","74105","79097",
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","74105",,,,,,,"fee schedule","74105","79097",
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","13242.33","13242.33","13242.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","12840","12840","12840","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","10451.66","10451.66","10451.66","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","116934",,,,,,,"fee schedule","102861","116934",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","102861",,,,,,,"fee schedule","102861","116934",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","116934",,,,,,,"fee schedule","102861","116934",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","76994",,,,,,,"fee schedule","67726","76994",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","67726",,,,,,,"fee schedule","67726","76994",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","76994",,,,,,,"fee schedule","67726","76994",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","51842",,,,,,,"fee schedule","45607","51842",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","45607",,,,,,,"fee schedule","45607","51842",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","51842",,,,,,,"fee schedule","45607","51842",
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","27241.07","27241.07","27241.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","5112.8","5112.8","5112.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","24559",,,,,,,"fee schedule","21562","24559",
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","21562",,,,,,,"fee schedule","21562","24559",
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","21994",,,,,,,"fee schedule","21562","24559",
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","24559",,,,,,,"fee schedule","21562","24559",
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","18998.4","18998.4","18998.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22560.67","22560.67","22560.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","16663.02","16663.02","16663.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","42466",,,,,,,"fee schedule","37362","42466",
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","42466",,,,,,,"fee schedule","37362","42466",
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","37362",,,,,,,"fee schedule","37362","42466",
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","31806.35","31806.35","31806.35","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","31875",,,,,,,"fee schedule","27985","31875",
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","27985",,,,,,,"fee schedule","27985","31875",
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","28542",,,,,,,"fee schedule","27985","31875",
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","31875",,,,,,,"fee schedule","27985","31875",
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","5738.77","5738.77","5738.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","15442","15442","15442","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","27407.63","27407.63","27407.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","32616","32616","32616","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","18250.42","18250.42","18250.42","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","9631","9631","9631","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Headaches Without Mcc","103","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","15442","15442","15442","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","131","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","72388",,,,,,,"fee schedule","54860","72388",
"Description Not Available","131","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","54860",,,,,,,"fee schedule","54860","72388",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","47036",,,,,,,"fee schedule","24867","54032",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","24867",,,,,,,"fee schedule","24867","54032",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","50069",,,,,,,"fee schedule","24867","54032",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","37944",,,,,,,"fee schedule","24867","54032",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","41607",,,,,,,"fee schedule","24867","54032",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","44826",,,,,,,"fee schedule","24867","54032",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","54032",,,,,,,"fee schedule","24867","54032",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","24867",,,,,,,"fee schedule","24867","54032",
"Description Not Available","132","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","47036",,,,,,,"fee schedule","24867","54032",
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40783",,,,,,,"fee schedule","30349","40783",
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30349",,,,,,,"fee schedule","30349","40783",
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33594",,,,,,,"fee schedule","30349","40783",
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","47523.69","47523.69","47523.69","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Head And Neck Procedures With Mcc","140","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","20752","20752","20752","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","85038",,,,,,,"fee schedule","85038","110431",
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","110431",,,,,,,"fee schedule","85038","110431",
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","91219",,,,,,,"fee schedule","85038","110431",
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","64864","64864","64864","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","46471",,,,,,,"fee schedule","46471","62446",
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","51437",,,,,,,"fee schedule","46471","62446",
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","62446",,,,,,,"fee schedule","46471","62446",
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","57828","57828","57828","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","24727",,,,,,,"fee schedule","24727","32111",
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","26524",,,,,,,"fee schedule","24727","32111",
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","32111",,,,,,,"fee schedule","24727","32111",
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","10872","10872","10872","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","55560",,,,,,,"fee schedule","50196","67453",
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","50196",,,,,,,"fee schedule","50196","67453",
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","67453",,,,,,,"fee schedule","50196","67453",
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","35417",,,,,,,"fee schedule","31997","42998",
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","31997",,,,,,,"fee schedule","31997","42998",
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","42998",,,,,,,"fee schedule","31997","42998",
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","26008",,,,,,,"fee schedule","19354","26008",
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19354",,,,,,,"fee schedule","19354","26008",
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","21422",,,,,,,"fee schedule","19354","26008",
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","24356",,,,,,,"fee schedule","18126","24356",
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","20061",,,,,,,"fee schedule","18126","24356",
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18126",,,,,,,"fee schedule","18126","24356",
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","70539",,,,,,,"fee schedule","54318","70539",
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","58267",,,,,,,"fee schedule","54318","70539",
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","54318",,,,,,,"fee schedule","54318","70539",
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18160",,,,,,,"fee schedule","18160","24401",
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","20100",,,,,,,"fee schedule","18160","24401",
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","24401",,,,,,,"fee schedule","18160","24401",
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","31437",,,,,,,"fee schedule","22983","31437",
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","26676",,,,,,,"fee schedule","22983","31437",
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","22983",,,,,,,"fee schedule","22983","31437",
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29847",,,,,,,"fee schedule","22983","31437",
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24580",,,,,,,"fee schedule","22983","31437",
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","26813",,,,,,,"fee schedule","22983","31437",
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","27652",,,,,,,"fee schedule","22983","31437",
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","31437",,,,,,,"fee schedule","22983","31437",
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","22644",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","16519",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","16172",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18209",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","21974",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","19882",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","21795",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","23648",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","19575",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","16172",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","20276",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","22644",,,,,,,"fee schedule","16172","23648",
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","6365.78","6365.78","6365.78","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","51118",,,,,,,"fee schedule","38040","51118",
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","38040",,,,,,,"fee schedule","38040","51118",
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","42104",,,,,,,"fee schedule","38040","51118",
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","32244",,,,,,,"fee schedule","23995","32244",
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","26558",,,,,,,"fee schedule","23995","32244",
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23995",,,,,,,"fee schedule","23995","32244",
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","12963",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","17766",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","12663",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","15389",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","17104",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","12663",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","14285",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","18552",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","17247",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","15599",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","15912",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","17766",,,,,,,"fee schedule","12663","18552",
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23749",,,,,,,"fee schedule","23749","31913",
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","26284",,,,,,,"fee schedule","23749","31913",
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","31913",,,,,,,"fee schedule","23749","31913",
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","181752",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","156530",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","118627",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","157996",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","142113",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","132875",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","172565",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","153575",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","158379",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","181752",,,,,,,"fee schedule","118627","181752",
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","147205","147205","147205","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","66725.92","66725.92","66725.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","151197","151197","151197","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","86238",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","81879",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","63046",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","56282",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","74265",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","67431",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","74961",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","72864",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","75140",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","86238",,,,,,,"fee schedule","56282","86238",
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","274363.05","274363.05","274363.05","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","43774.14","43774.14","43774.14","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","28391.73","28391.73","28391.73","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Chest Procedures With Cc","164","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","62704",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","45887",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","44773",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","61046",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","60547",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","50422",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","55054",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","54086",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","65483",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","44773",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","56152",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","62704",,,,,,,"fee schedule","44773","65483",
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","56940","56940","56940","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","211449","211449","211449","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","19728.68","19728.68","19728.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21397.38","21397.38","21397.38","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","33095",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","24205",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","32200",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","34561",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","31936",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","23647",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","26612",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28687",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","23647",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","29056",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","29635",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","33095",,,,,,,"fee schedule","23647","34561",
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","12390.5","12390.5","12390.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","39969",,,,,,,"fee schedule","37260","48387",
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","37260",,,,,,,"fee schedule","37260","48387",
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","48387",,,,,,,"fee schedule","37260","48387",
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19430",,,,,,,"fee schedule","19430","25233",
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","25233",,,,,,,"fee schedule","19430","25233",
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","20842",,,,,,,"fee schedule","19430","25233",
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","20726.85","20726.85","20726.85","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","29760.59","29760.59","29760.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","20359.26","20359.26","20359.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","12709.42","12709.42","12709.42","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28335",,,,,,,"fee schedule","25599","34399",
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","25599",,,,,,,"fee schedule","25599","34399",
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","34399",,,,,,,"fee schedule","25599","34399",
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","7710.45","7710.45","7710.45","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","21912","21912","21912","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","28798","28798","28798","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","41924","41924","41924","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","14927.93","14927.93","14927.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","32790",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","50245",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","43672",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","43266",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","36732",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","39287",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","47706",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","42450",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","43776",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","50245",,,,,,,"fee schedule","32790","50245",
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","25.31","25.31","25.31","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","42030",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","27433",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","36538",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","36198",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","35516",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30727",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","39906",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","32865",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","36626",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","42030",,,,,,,"fee schedule","27433","42030",
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","28738",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","20520",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","27700",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","20994",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","20520",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","30013",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23109",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24801",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","25232",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","27926",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","25734",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","28738",,,,,,,"fee schedule","20520","30013",
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","56796",,,,,,,"fee schedule","52947","68758",
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","68758",,,,,,,"fee schedule","52947","68758",
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","52947",,,,,,,"fee schedule","52947","68758",
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","66587","66587","66587","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","34848.49","34848.49","34848.49","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","15486.51","15486.51","15486.51","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","33976",,,,,,,"fee schedule","33976","44122",
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","36446",,,,,,,"fee schedule","33976","44122",
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","44122",,,,,,,"fee schedule","33976","44122",
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","14771.4","14771.4","14771.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","26128",,,,,,,"fee schedule","18611","27284",
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21010",,,,,,,"fee schedule","18611","27284",
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","27284",,,,,,,"fee schedule","18611","27284",
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","18611",,,,,,,"fee schedule","18611","27284",
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","18611",,,,,,,"fee schedule","18611","27284",
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","22709",,,,,,,"fee schedule","18611","27284",
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","22940",,,,,,,"fee schedule","18611","27284",
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","26128",,,,,,,"fee schedule","18611","27284",
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","9455.06","9455.06","9455.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","65959",,,,,,,"fee schedule","65959","85657",
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","70755",,,,,,,"fee schedule","65959","85657",
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","85657",,,,,,,"fee schedule","65959","85657",
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","82063.68","82063.68","82063.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","20","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","286050",,,,,,,"fee schedule","262365","421727",
"Description Not Available","20","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","346192",,,,,,,"fee schedule","262365","421727",
"Description Not Available","20","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","262365",,,,,,,"fee schedule","262365","421727",
"Description Not Available","20","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","309113",,,,,,,"fee schedule","262365","421727",
"Description Not Available","20","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","286050",,,,,,,"fee schedule","262365","421727",
"Description Not Available","20","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","401144",,,,,,,"fee schedule","262365","421727",
"Description Not Available","20","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","330644",,,,,,,"fee schedule","262365","421727",
"Description Not Available","20","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","421727",,,,,,,"fee schedule","262365","421727",
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","44504",,,,,,,"fee schedule","44504","57794",
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","57794",,,,,,,"fee schedule","44504","57794",
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","47738",,,,,,,"fee schedule","44504","57794",
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28521",,,,,,,"fee schedule","26589","34529",
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","34529",,,,,,,"fee schedule","26589","34529",
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","26589",,,,,,,"fee schedule","26589","34529",
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","26687",,,,,,,"fee schedule","26687","34656",
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28627",,,,,,,"fee schedule","26687","34656",
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","34656",,,,,,,"fee schedule","26687","34656",
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","11573.95","11573.95","11573.95","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","52457.46","52457.46","52457.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","7566.16","7566.16","7566.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","25648",,,,,,,"fee schedule","19751","25648",
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19751",,,,,,,"fee schedule","19751","25648",
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","21186",,,,,,,"fee schedule","19751","25648",
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","26227",,,,,,,"fee schedule","19517","26227",
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19517",,,,,,,"fee schedule","19517","26227",
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","21603",,,,,,,"fee schedule","19517","26227",
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","9531.15","9531.15","9531.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Respiratory Signs And Symptoms","204","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","57826.03","57826.03","57826.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","31410",,,,,,,"fee schedule","23374","31410",
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23374",,,,,,,"fee schedule","23374","31410",
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","25871",,,,,,,"fee schedule","23374","31410",
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","216189",,,,,,,"fee schedule","216189","280748",
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","280748",,,,,,,"fee schedule","216189","280748",
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","231903",,,,,,,"fee schedule","216189","280748",
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","143177",,,,,,,"fee schedule","133476","173335",
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","133476",,,,,,,"fee schedule","133476","173335",
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","173335",,,,,,,"fee schedule","133476","173335",
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","30800.2","30800.2","30800.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","1104999","1104999","1104999","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","238978",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","235357.34",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","266222",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","194584",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","256755",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","220032",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","285542.01",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","252707",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","238978",,,,,,,"fee schedule","194584","285542.01",
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","21","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","262177",,,,,,,"fee schedule","215139","316241",
"Description Not Available","21","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","286050",,,,,,,"fee schedule","215139","316241",
"Description Not Available","21","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","215139",,,,,,,"fee schedule","215139","316241",
"Description Not Available","21","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","283878",,,,,,,"fee schedule","215139","316241",
"Description Not Available","21","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","231396",,,,,,,"fee schedule","215139","316241",
"Description Not Available","21","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","300287",,,,,,,"fee schedule","215139","316241",
"Description Not Available","21","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","286050",,,,,,,"fee schedule","215139","316241",
"Description Not Available","21","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","316241",,,,,,,"fee schedule","215139","316241",
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","133227",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","94220",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","124325",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","138362.23",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","129109",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","106618",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","114045.82",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","122566",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","133227",,,,,,,"fee schedule","94220","138362.23",
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","550281",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","389884",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","533607",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","514453",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","572437",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","408200",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","471835",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","441110",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","408200",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","466244",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","505850",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","550281",,,,,,,"fee schedule","389884","572437",
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","382102",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","397671",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","283582",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","357051",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","270594",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","306437",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","327783",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","370752",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","283582",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","418096",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","351313",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","382102",,,,,,,"fee schedule","270594","418096",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","312630",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","243536",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","321347",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","347020",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","251811",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","285309",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","326783",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","283582",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","283582",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","333678",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","316182",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","312630",,,,,,,"fee schedule","243536","347020",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","130800.34","130800.34","130800.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","71420.22","71420.22","71420.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","295260",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","303493",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","230005",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","269459",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","308628",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","283582",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","237822",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","283582",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","326115",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","315139",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","298616",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","295260",,,,,,,"fee schedule","230005","326115",
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","274431",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","235380",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","266222",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","256755",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","194584",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","203642",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","285570",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","300312",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","203642",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","220053",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","252346",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","274431",,,,,,,"fee schedule","194584","300312",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","123051.94","123051.94","123051.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","403540.72","403540.72","403540.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","1375","1375","1375","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","276554","276554","276554","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","275143.62","275143.62","275143.62","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","22","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","309113",,,,,,,"fee schedule","262365","421727",
"Description Not Available","22","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","262365",,,,,,,"fee schedule","262365","421727",
"Description Not Available","22","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","346192",,,,,,,"fee schedule","262365","421727",
"Description Not Available","22","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","330644",,,,,,,"fee schedule","262365","421727",
"Description Not Available","22","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","401144",,,,,,,"fee schedule","262365","421727",
"Description Not Available","22","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","286097",,,,,,,"fee schedule","262365","421727",
"Description Not Available","22","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","286097",,,,,,,"fee schedule","262365","421727",
"Description Not Available","22","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","421727",,,,,,,"fee schedule","262365","421727",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","172044",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","203642",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","186073",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","134264",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","177161",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","179807",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","138554",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","156987",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","203642",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","183588",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","174019",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","172044",,,,,,,"fee schedule","134264","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","166606","166606","166606","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","166128","166128","166128","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","156856",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","203642",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","167790",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","122589",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","161756",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","163932",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","126322",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","143127",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","203642",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","167382",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","158656",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","156856",,,,,,,"fee schedule","122589","203642",
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","209302",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","187252",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","162750",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","214750",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","218606",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","187252",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","168454",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","190858",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","232428",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","223167",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","211551",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","209302",,,,,,,"fee schedule","162750","232428",
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","206531",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","187252",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","231802",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","169904",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","224189",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","227064",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","210990",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","198244",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","174972",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","187252",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","219737",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","206531",,,,,,,"fee schedule","169904","231802",
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","85212.64","85212.64","85212.64","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","23","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","176877",,,,,,,"fee schedule","176877","260849",
"Description Not Available","23","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","201006",,,,,,,"fee schedule","176877","260849",
"Description Not Available","23","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","233391",,,,,,,"fee schedule","176877","260849",
"Description Not Available","23","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","260849",,,,,,,"fee schedule","176877","260849",
"Description Not Available","23","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","239155",,,,,,,"fee schedule","176877","260849",
"Description Not Available","23","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","215009",,,,,,,"fee schedule","176877","260849",
"Description Not Available","23","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","186014",,,,,,,"fee schedule","176877","260849",
"Description Not Available","23","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","186014",,,,,,,"fee schedule","176877","260849",
"Description Not Available","230","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","178847",,,,,,,"fee schedule","178847","235989",
"Description Not Available","230","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","235989",,,,,,,"fee schedule","178847","235989",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","285598",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","295005",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","223573",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","260227",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","298300",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","260441",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","229863",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","260227",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","304554",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","316576",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","288772",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","285598",,,,,,,"fee schedule","223573","316576",
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","289051",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","298284",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","308236",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","260227",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","226056",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","232642",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","260227",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","263589",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","301904",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","320729",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","292262",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","289051",,,,,,,"fee schedule","226056","320729",
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","258503",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","241888",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","183316",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","207185",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","191732",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","268871",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","221621",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","191732",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","250822",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","283168",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","237699",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","258503",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","183316",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","258503",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","241888",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","207185",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","191732",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","250822",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","268871",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","191732",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","221621",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","283168",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","237699",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","258503",,,,,,,"fee schedule","183316","283168",
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","189448",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","176992",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","134136",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","162459",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","140549",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","151882",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","197101",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","140549",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","207134",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","183626",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","189448",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","174160",,,,,,,"fee schedule","134136","207134",
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","126145","126145","126145","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","166448","166448","166448","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","68633.11","68633.11","68633.11","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","157330","157330","157330","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","64246.34","64246.34","64246.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","75200.98","75200.98","75200.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","189448",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","176992",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","134136",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","140549",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","180465",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","162459",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","151882",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","197101",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","140549",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","183626",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","174160",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","189448",,,,,,,"fee schedule","134136","197101",
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","166448","166448","166448","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","24","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","231056",,,,,,,"fee schedule","175109","257283",
"Description Not Available","24","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","219145",,,,,,,"fee schedule","175109","257283",
"Description Not Available","24","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","175109",,,,,,,"fee schedule","175109","257283",
"Description Not Available","24","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","198258",,,,,,,"fee schedule","175109","257283",
"Description Not Available","24","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","186014",,,,,,,"fee schedule","175109","257283",
"Description Not Available","24","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","212067",,,,,,,"fee schedule","175109","257283",
"Description Not Available","24","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","257283",,,,,,,"fee schedule","175109","257283",
"Description Not Available","24","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","186014",,,,,,,"fee schedule","175109","257283",
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","153146",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","149239",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","155910",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","136122",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","166687",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","116064",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","126635",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","120140",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","126635",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","159065",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","149239",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","150808",,,,,,,"fee schedule","116064","166687",
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","113669",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","105960",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","91061",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","97403",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","84267",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","80301",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","118173",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","110130",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","84267",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","124237",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","113669",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","104437",,,,,,,"fee schedule","80301","124237",
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","85755",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","87946",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","78175",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","66652",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","94407",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","91394",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","68998",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","89540",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","84267",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","84267",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","85755",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","86669",,,,,,,"fee schedule","66652","94407",
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","81069.8","81069.8","81069.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","25","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","139312",,,,,,,"fee schedule","112936","173817",
"Description Not Available","25","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","131729",,,,,,,"fee schedule","112936","173817",
"Description Not Available","25","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","127961",,,,,,,"fee schedule","112936","173817",
"Description Not Available","25","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","173817",,,,,,,"fee schedule","112936","173817",
"Description Not Available","25","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","164424",,,,,,,"fee schedule","112936","173817",
"Description Not Available","25","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","146562",,,,,,,"fee schedule","112936","173817",
"Description Not Available","25","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","112936",,,,,,,"fee schedule","112936","173817",
"Description Not Available","25","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","139312",,,,,,,"fee schedule","112936","173817",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","59736",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","84566",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","62782",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","72563",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","81897",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","78822",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","67837",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","88035",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","62782",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","92573",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","84566",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","77723",,,,,,,"fee schedule","59736","92573",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","64858",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","69092",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","50177",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","52255",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","67813",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","66209",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","59205",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","62782",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","62782",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","71620",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","77723",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","64858",,,,,,,"fee schedule","50177","77723",
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","151309",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","107310",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","141594",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","129754",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","146761",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","112254",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","157419",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","112254",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","121304",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","144264",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","139131",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","151309",,,,,,,"fee schedule","107310","157419",
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","85253","85253","85253","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","46600.33","46600.33","49775.74","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","101432",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","94629",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","71716",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","81202",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","98227",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","105379",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","86859",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","75148",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","75148",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","96643",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","93128",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","101432",,,,,,,"fee schedule","71716","105379",
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","70245",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","65605",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","49720",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","60229",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","56308",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","73071",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","52110",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","52110",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","76843",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","68129",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","70245",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","64504",,,,,,,"fee schedule","49720","76843",
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","41708.62","41708.62","41708.62","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","77401",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","72449",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","84508",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","80443",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","75132",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","54905",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","57365",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","61987",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","66306",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","57365",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","71115",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","77401",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","77401",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","80443",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","75132",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","57365",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","72449",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","54905",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","57365",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","61987",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","66306",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","84508",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","71115",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","77401",,,,,,,"fee schedule","54905","84508",
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","26","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","102418",,,,,,,"fee schedule","77618","113837",
"Description Not Available","26","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","87721",,,,,,,"fee schedule","77618","113837",
"Description Not Available","26","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","77618",,,,,,,"fee schedule","77618","113837",
"Description Not Available","26","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","81179",,,,,,,"fee schedule","77618","113837",
"Description Not Available","26","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","93830",,,,,,,"fee schedule","77618","113837",
"Description Not Available","26","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","113837",,,,,,,"fee schedule","77618","113837",
"Description Not Available","26","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","81179",,,,,,,"fee schedule","77618","113837",
"Description Not Available","26","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","104554",,,,,,,"fee schedule","77618","113837",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","67218",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","53969",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","49940",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","73615",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","47752",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","63008",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","57730",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","70037",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","49940",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","65332",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","61883",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","67218",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","67218",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","47752",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","63008",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","57730",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","53969",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","49940",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","70037",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","49940",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","65332",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","73615",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","61883",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","67218",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","67218",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","47752",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","63008",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","57730",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","49940",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","65332",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","53969",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","70037",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","49940",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","73615",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","61883",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","67218",,,,,,,"fee schedule","47752","73615",
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","107522",,,,,,,"fee schedule","80014","107522",
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","80014",,,,,,,"fee schedule","80014","107522",
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","88565",,,,,,,"fee schedule","80014","107522",
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","57828","57828","57828","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","40192.89","40192.89","40192.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","301350",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","213587",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","281829",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","313594",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","241650",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","258481",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","214414",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","214414",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","287301",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","292355",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","429000",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","301350",,,,,,,"fee schedule","213587","429000",
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","69843.99","69843.99","69845.55","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","80576.63","80576.63","80576.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","68008.69","68008.69","68008.69","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","111583.33","111583.33","111583.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]","280162","280162","280162","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","68500.71","68500.71","68500.71","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","199882",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","160980",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","189507",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","155919",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","205738",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","214414",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","182394",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","208906",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","214414",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","213306",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","239033",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","199882",,,,,,,"fee schedule","155919","239033",
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","194060","194060","194060","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","164487.6","164487.6","164487.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","62616.1","62616.1","62616.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","183010","183010","183010","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","37273.21","37273.21","37273.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","52984.86","52984.86","52984.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","182182",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","194975",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","138069",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","213184",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","188995",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","138594",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","156226",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","202741",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","167107",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","138594",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","179138",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","194975",,,,,,,"fee schedule","138069","213184",
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","166681.78","166681.78","166681.78","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","119673",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","111624",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","124247",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","84595",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","84973",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","130491",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","102411",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","95741",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","84973",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","115963",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","109934",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","119673",,,,,,,"fee schedule","84595","130491",
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","47063.57","47063.57","47063.57","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","27","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","62953",,,,,,,"fee schedule","62953","100433",
"Description Not Available","27","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","83069",,,,,,,"fee schedule","62953","100433",
"Description Not Available","27","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","77391",,,,,,,"fee schedule","62953","100433",
"Description Not Available","27","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","82572",,,,,,,"fee schedule","62953","100433",
"Description Not Available","27","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","87689",,,,,,,"fee schedule","62953","100433",
"Description Not Available","27","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","82572",,,,,,,"fee schedule","62953","100433",
"Description Not Available","27","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","100433",,,,,,,"fee schedule","62953","100433",
"Description Not Available","27","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","76826",,,,,,,"fee schedule","62953","100433",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","158028",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","165035",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","144087",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","162143",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","122881",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","127174",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","138594",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","138594",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","168499",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","152592",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","159711",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","158028",,,,,,,"fee schedule","122881","168499",
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","116864.52","116864.52","116864.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","59831.88","59831.88","59831.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","116597",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","82466",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","90953",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","103051",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","138594",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","88365",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","118033",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","138594",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","120510",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","105432",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","82466",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","114226",,,,,,,"fee schedule","82466","138594",
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","80064","80064","80064","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","109651","109651","109651","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","50830.7","50830.7","50830.7","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","101817","101817","101817","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","119673",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","84973",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","61755",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","81485",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","75270",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","102411",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","84973",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","95741",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","124247",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","84891",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","80478",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","119673",,,,,,,"fee schedule","61755","124247",
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","59679.04","59679.04","59679.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","91940",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","105281",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","94585",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","94422",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","71683",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","86779",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","81128",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","60180",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","60180",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","97942",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","90527",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","91940",,,,,,,"fee schedule","60180","105281",
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","45782.15","45782.15","45782.15","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","92582.84","92582.84","92582.84","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","89104",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","92759",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","62721",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","82761",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","71479",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","60180",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","92573",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","76457",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","60180",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","86293",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","80564",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","89104",,,,,,,"fee schedule","60180","92759",
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","153601","153601","153601","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","78550.01","78550.01","78550.01","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","202677","202677","202677","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","89831","89831","89831","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","42169.28","42169.28","42169.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","76920.21","76920.21","76920.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","298998",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","311899",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","307392",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","222723",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","293885",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","330743",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","240343",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","266267",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","243321",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","243321",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","298998",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","302953",,,,,,,"fee schedule","222723","330743",
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","80236.33","80236.33","80236.33","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","171486.24","171486.24","171486.24","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","256427",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","220011",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","280345",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","181527",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","239527",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","266923",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","205686",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","189439",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","189439",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","248722",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","256427",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","235825",,,,,,,"fee schedule","181527","280345",
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","258496","258496","258496","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","210584",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","245725",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","163907",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","216277",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","170169",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","203065",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","203065",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","281441",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","225398",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","233100",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","252808",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","210584",,,,,,,"fee schedule","163907","281441",
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","28","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","149413",,,,,,,"fee schedule","123402","190594",
"Description Not Available","28","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","181272",,,,,,,"fee schedule","123402","190594",
"Description Not Available","28","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","129264",,,,,,,"fee schedule","123402","190594",
"Description Not Available","28","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","162830",,,,,,,"fee schedule","123402","190594",
"Description Not Available","28","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","123402",,,,,,,"fee schedule","123402","190594",
"Description Not Available","28","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","129264",,,,,,,"fee schedule","123402","190594",
"Description Not Available","28","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","139686",,,,,,,"fee schedule","123402","190594",
"Description Not Available","28","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","190594",,,,,,,"fee schedule","123402","190594",
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","75517",,,,,,,"fee schedule","75517","98069",
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","98069",,,,,,,"fee schedule","75517","98069",
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","81007",,,,,,,"fee schedule","75517","98069",
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","11187.29","11187.29","11187.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","100793","100793","100793","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","35504",,,,,,,"fee schedule","33098","42982",
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","33098",,,,,,,"fee schedule","33098","42982",
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","42982",,,,,,,"fee schedule","33098","42982",
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","7510.4","7510.4","7510.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","17344.06","17344.06","17344.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","27345",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","19961",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","23755",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","19528",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","26338",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","19528",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","26553",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","24009",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","28559",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21990",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","24490",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","27345",,,,,,,"fee schedule","19528","28559",
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","24769","24769","24769","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","69060",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","49006",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","55473",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","71989",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","51341",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","75635",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","64662",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","59336",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","51341",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","66963",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","63502",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","69060",,,,,,,"fee schedule","49006","75635",
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","22000","22000","22000","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","32110.29","32110.29","32110.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","46086","46086","46086","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","57463","57463","57463","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","37100.67","37100.67","37100.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","27599.52","27599.52","27599.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","60622","60622","60622","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","52662",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","45219",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","37379",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","49321",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","42274",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","39112",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","54860",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","39112",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","51099",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","57681",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","48431",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","52662",,,,,,,"fee schedule","37379","57681",
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","43123.12","43123.12","43123.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","48998.54","48998.54","48998.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","16279.78","16279.78","16279.78","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","46235","46235","46235","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","29","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","129264",,,,,,,"fee schedule","74041","129264",
"Description Not Available","29","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","100108",,,,,,,"fee schedule","74041","129264",
"Description Not Available","29","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","74041",,,,,,,"fee schedule","74041","129264",
"Description Not Available","29","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","97698",,,,,,,"fee schedule","74041","129264",
"Description Not Available","29","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","86015",,,,,,,"fee schedule","74041","129264",
"Description Not Available","29","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","75916",,,,,,,"fee schedule","74041","129264",
"Description Not Available","29","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","98517",,,,,,,"fee schedule","74041","129264",
"Description Not Available","29","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","129264",,,,,,,"fee schedule","74041","129264",
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","12501.1","12501.1","12501.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","23924.91","23924.91","23924.91","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","47321","47321","52600","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","26564","26564","26564","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","10761.99","10761.99","10761.99","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","15801","15801","15801","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","12501.1","12501.1","12501.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","65132",,,,,,,"fee schedule","65132","84583",
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","84583",,,,,,,"fee schedule","65132","84583",
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","69868",,,,,,,"fee schedule","65132","84583",
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","91269","91269","91269","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","38863.57","38863.57","38863.57","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","16240","16240","16240","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]","1676","1676","1676","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","18887.96","18887.96","18887.96","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","30","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","70774",,,,,,,"fee schedule","58661","90559",
"Description Not Available","30","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","61232",,,,,,,"fee schedule","58661","90559",
"Description Not Available","30","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","77405",,,,,,,"fee schedule","58661","90559",
"Description Not Available","30","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","58661",,,,,,,"fee schedule","58661","90559",
"Description Not Available","30","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","61232",,,,,,,"fee schedule","58661","90559",
"Description Not Available","30","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","85866",,,,,,,"fee schedule","58661","90559",
"Description Not Available","30","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","66167",,,,,,,"fee schedule","58661","90559",
"Description Not Available","30","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","90559",,,,,,,"fee schedule","58661","90559",
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","42870",,,,,,,"fee schedule","33012","42870",
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","33012",,,,,,,"fee schedule","33012","42870",
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","35412",,,,,,,"fee schedule","33012","42870",
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","10067.19","10067.19","10067.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","22722",,,,,,,"fee schedule","17498","22722",
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","17498",,,,,,,"fee schedule","17498","22722",
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","18770",,,,,,,"fee schedule","17498","22722",
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","18468",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","25256",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","24369",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","21814",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","26377",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","20310",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","18002",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","18002",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","24571",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","22174",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","25256",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","22617",,,,,,,"fee schedule","18002","26377",
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","17368","17368","17368","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","52567",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","34306",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","44413",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","45269",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","45690",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","49910",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","38430",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","41104",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","52567",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","45800",,,,,,,"fee schedule","34306","52567",
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","19923",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","30523",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","28980",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","26288",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","22313",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","23865",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","26534",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","25793",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","26596",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","30523",,,,,,,"fee schedule","19923","30523",
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","11095.86","11095.86","11095.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","49349",,,,,,,"fee schedule","49349","64087",
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","52937",,,,,,,"fee schedule","49349","64087",
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","64087",,,,,,,"fee schedule","49349","64087",
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","46705.13","46705.13","46705.13","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21434.13","21434.13","21434.13","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","39963",,,,,,,"fee schedule","30773","39963",
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30773",,,,,,,"fee schedule","30773","39963",
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33010",,,,,,,"fee schedule","30773","39963",
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","9332.18","9332.18","9332.18","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","11419.63","11419.63","11419.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","27016.3","27016.3","27016.3","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","40606.92","40606.92","40606.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","8929.22","8929.22","8929.22","1 through 10","other",,,"Contracting method is an algorithm described in 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 Not Available","31","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","88350",,,,,,,"fee schedule","88350","136342",
"Description Not Available","31","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","99919",,,,,,,"fee schedule","88350","136342",
"Description Not Available","31","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","136342",,,,,,,"fee schedule","88350","136342",
"Description Not Available","31","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","116578",,,,,,,"fee schedule","88350","136342",
"Description Not Available","31","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","106878",,,,,,,"fee schedule","88350","136342",
"Description Not Available","31","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","129668",,,,,,,"fee schedule","88350","136342",
"Description Not Available","31","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","92471",,,,,,,"fee schedule","88350","136342",
"Description Not Available","31","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","92471",,,,,,,"fee schedule","88350","136342",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","19336",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","20192",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","13806",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","14111",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","18618",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","13806",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","18773",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","15548",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","16735",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","16976",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","17312",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","19336",,,,,,,"fee schedule","13806","20192",
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","1027.29","1027.29","1027.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","22644",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18209",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","21974",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","19882",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","21795",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","16519",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","19575",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","23648",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","16172",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","16172",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","20276",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","22644",,,,,,,"fee schedule","16172","23648",
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","9785.78","9785.78","9785.78","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","19856",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","14569",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","14188",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","15968",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","17185",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","19382",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","20737",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","19224",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","14188",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","17432",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","17783",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","19856",,,,,,,"fee schedule","14188","20737",
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","24871.04","24871.04","24871.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","32489.26","32489.26","32489.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","65232","65232","65232","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","23570.56","23570.56","23570.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","25682",,,,,,,"fee schedule","25682","34508",
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28424",,,,,,,"fee schedule","25682","34508",
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","34508",,,,,,,"fee schedule","25682","34508",
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","20752","20752","20752","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","14629.47","14629.47","14629.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","14411","14411","14411","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19085",,,,,,,"fee schedule","19085","25646",
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","21124",,,,,,,"fee schedule","19085","25646",
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","25646",,,,,,,"fee schedule","19085","25646",
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","163332",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","147049",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","215517",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","219500",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","185268",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","185268",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","169143",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","191044",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","209023",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","182243",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","146656",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","147049",,,,,,,"fee schedule","146656","219500",
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","76648",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","67830",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","81897",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","59736",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","78822",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","72555.84",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","88026.82",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","77835",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","76648",,,,,,,"fee schedule","59736","88026.82",
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","208452",,,,,,,"fee schedule","152394","208452",
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","171186",,,,,,,"fee schedule","152394","208452",
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","162989",,,,,,,"fee schedule","152394","208452",
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","152394",,,,,,,"fee schedule","152394","208452",
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","197915",,,,,,,"fee schedule","152394","208452",
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","170087",,,,,,,"fee schedule","152394","208452",
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","177383",,,,,,,"fee schedule","152394","208452",
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","208452",,,,,,,"fee schedule","152394","208452",
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","32","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","111918",,,,,,,"fee schedule","84819","124311",
"Description Not Available","32","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","84819",,,,,,,"fee schedule","84819","124311",
"Description Not Available","32","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","102465",,,,,,,"fee schedule","84819","124311",
"Description Not Available","32","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","92471",,,,,,,"fee schedule","84819","124311",
"Description Not Available","32","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","95791",,,,,,,"fee schedule","84819","124311",
"Description Not Available","32","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","124311",,,,,,,"fee schedule","84819","124311",
"Description Not Available","32","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","92471",,,,,,,"fee schedule","84819","124311",
"Description Not Available","32","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","121166",,,,,,,"fee schedule","84819","124311",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","119342",,,,,,,"fee schedule","87247","119342",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","87247",,,,,,,"fee schedule","87247","119342",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","93314",,,,,,,"fee schedule","87247","119342",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","113310",,,,,,,"fee schedule","87247","119342",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","98006",,,,,,,"fee schedule","87247","119342",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","97376",,,,,,,"fee schedule","87247","119342",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","101554",,,,,,,"fee schedule","87247","119342",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","119342",,,,,,,"fee schedule","87247","119342",
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","143521",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","105930",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","115001",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","123007",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","149240",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","134129",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","101651",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","105930",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","157146",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","139144",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","131924",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","143521",,,,,,,"fee schedule","101651","157146",
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","522.5","522.5","522.5","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","126138","126138","126138","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","38629.13","38629.13","38629.13","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","32883.08","32883.08","32883.08","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","117745",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","86883",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","114017",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","83464",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","94339",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","110129",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","100909",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","122426",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","128589",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","86883",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","108151",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","117745",,,,,,,"fee schedule","83464","128589",
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","103568","103568","103568","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","124180","124180","124180","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","103247","103247","103247","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","66174.67","66174.67","66174.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","12715.76","12715.76","12715.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","110865.6","110865.6","110865.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]","89560","89560","89560","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","10078.32","10078.32","10078.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","57644","57644","57644","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","70861.48","70861.48","70861.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","112173",,,,,,,"fee schedule","86379","112173",
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","86379",,,,,,,"fee schedule","86379","112173",
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","92657",,,,,,,"fee schedule","86379","112173",
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","105786","105786","105786","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","73040","73040","73040","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","28091.93","28091.93","28091.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","83652","83652","83652","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","89732","89732","89732","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","9631","9631","9631","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","27514.97","27514.97","27514.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","20788",,,,,,,"fee schedule","20788","26995",
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","26995",,,,,,,"fee schedule","20788","26995",
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","22298",,,,,,,"fee schedule","20788","26995",
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22805.8","22805.8","22805.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","96380.93","96380.93","96380.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","33","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","47752",,,,,,,"fee schedule","47752","73615",
"Description Not Available","33","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","63008",,,,,,,"fee schedule","47752","73615",
"Description Not Available","33","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","70037",,,,,,,"fee schedule","47752","73615",
"Description Not Available","33","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","53969",,,,,,,"fee schedule","47752","73615",
"Description Not Available","33","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","49940",,,,,,,"fee schedule","47752","73615",
"Description Not Available","33","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","73615",,,,,,,"fee schedule","47752","73615",
"Description Not Available","33","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","57730",,,,,,,"fee schedule","47752","73615",
"Description Not Available","33","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","49940",,,,,,,"fee schedule","47752","73615",
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","56676",,,,,,,"fee schedule","42177","56676",
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","42177",,,,,,,"fee schedule","42177","56676",
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","46683",,,,,,,"fee schedule","42177","56676",
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","77104","77104","77104","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","109560","109560","109560","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","40845","40845","40845","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","26998.55","26998.55","26998.55","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","47797",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","46264",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","35061",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","49914",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","41163",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","31656",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","38433",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","31656",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","44485",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","41964",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","42106",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","47797",,,,,,,"fee schedule","31656","49914",
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","32973","32973","32973","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","43508","43508","43508","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","40197","40197","40197","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","43562",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","46288",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","35080",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","38530",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","41431",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","50039",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","31044",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","31044",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","44123",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","42071",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","42213",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","43562",,,,,,,"fee schedule","31044","50039",
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","132043",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","103245",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","114787",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","96534",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","111574",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","86187",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","113721",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","125368",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","115063",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","132043",,,,,,,"fee schedule","86187","132043",
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","76140.57","76140.57","76140.57","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","76530",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","65912",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","72661",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","49951",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","59838",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","55950",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","66531",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","64670",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","76530",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","66691",,,,,,,"fee schedule","49951","76530",
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","61986","61986","61986","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","70367","70367","70367","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","24945",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","38227",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","27947",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","29890",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","32295",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","32916",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","36295",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","33224",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","33306",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","38227",,,,,,,"fee schedule","24945","38227",
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","30955","30955","30955","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","200","200","200","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","38321",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","28105",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","37084",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33168",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30814",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","27307",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40017",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","27307",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","37390",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","33644",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","34313",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","38321",,,,,,,"fee schedule","27307","40017",
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","71969",,,,,,,"fee schedule","65023","87376",
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","65023",,,,,,,"fee schedule","65023","87376",
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","87376",,,,,,,"fee schedule","65023","87376",
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","35565",,,,,,,"fee schedule","35565","47792",
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","39365",,,,,,,"fee schedule","35565","47792",
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","47792",,,,,,,"fee schedule","35565","47792",
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","32363",,,,,,,"fee schedule","24083","32363",
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","26656",,,,,,,"fee schedule","24083","32363",
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","24083",,,,,,,"fee schedule","24083","32363",
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","26079",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","21118",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23069",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24959",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","27865",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","17393",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29958",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","17393",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","26902",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","25186",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","25018",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","26079",,,,,,,"fee schedule","17393","29958",
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","81042",,,,,,,"fee schedule","59249","81042",
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","63368",,,,,,,"fee schedule","59249","81042",
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","76947",,,,,,,"fee schedule","59249","81042",
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","59249",,,,,,,"fee schedule","59249","81042",
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","68770",,,,,,,"fee schedule","59249","81042",
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","69128",,,,,,,"fee schedule","59249","81042",
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","81042",,,,,,,"fee schedule","59249","81042",
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","71288",,,,,,,"fee schedule","59249","81042",
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","144570","144570","144570","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","30672",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","46994",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","39707",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","40472",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","34357",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","36744",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","44618",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","40852",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","40949",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","46994",,,,,,,"fee schedule","30672","46994",
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","38060","38060","38060","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","35584","35584","35584","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","29864",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","34308",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","23974",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","28842",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","31633",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","26417",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28343",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","21280",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","30158",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","21280",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","28940",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","29864",,,,,,,"fee schedule","21280","34308",
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","72909.52","72909.52","72909.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","28914","28914","28914","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","30876","30876","30876","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","28893","28893","28893","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","143521",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","101651",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","134129",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","114990",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","122995.53",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","149225.16",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","139144",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","143521",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","132113",,,,,,,"fee schedule","101651","149225.16",
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","117745",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","83464",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","110129",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","94330",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","100899",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","122414.23",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","114017",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","108306",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","117745",,,,,,,"fee schedule","83464","122414.23",
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","18150.58","18150.58","18150.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Esophageal Disorders With Mcc","368","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","26491",,,,,,,"fee schedule","26491","35599",
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","29321",,,,,,,"fee schedule","26491","35599",
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","35599",,,,,,,"fee schedule","26491","35599",
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","37","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","68803",,,,,,,"fee schedule","68803","106141",
"Description Not Available","37","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","101247",,,,,,,"fee schedule","68803","106141",
"Description Not Available","37","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","72395",,,,,,,"fee schedule","68803","106141",
"Description Not Available","37","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","81789",,,,,,,"fee schedule","68803","106141",
"Description Not Available","37","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","95525",,,,,,,"fee schedule","68803","106141",
"Description Not Available","37","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","68803",,,,,,,"fee schedule","68803","106141",
"Description Not Available","37","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","87485",,,,,,,"fee schedule","68803","106141",
"Description Not Available","37","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","106141",,,,,,,"fee schedule","68803","106141",
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18399",,,,,,,"fee schedule","18399","24723",
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","24723",,,,,,,"fee schedule","18399","24723",
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","20364",,,,,,,"fee schedule","18399","24723",
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","9631","9631","9631","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","20560.77","20560.77","20560.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","19546.39","19546.39","19546.39","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","33965",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","32847",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","24893",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","35471",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","24256",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","27312",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","29434",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","24256",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","33116",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","29822",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","30413",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","33965",,,,,,,"fee schedule","24256","35471",
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","27749.09","27749.09","27749.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","29034","29034","29034","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","84065",,,,,,,"fee schedule","84065","109170",
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","90177",,,,,,,"fee schedule","84065","109170",
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","109170",,,,,,,"fee schedule","84065","109170",
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","24669.04","24669.04","24669.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","199772.37","199772.37","199772.37","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","66995.45","66995.45","66995.45","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","30393.89","30393.89","30393.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]","37590","37590","37590","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","24517.59","24517.59","24517.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","48243",,,,,,,"fee schedule","44974","58404",
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","58404",,,,,,,"fee schedule","44974","58404",
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","44974",,,,,,,"fee schedule","44974","58404",
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","28029.29","28029.29","28029.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","99326",,,,,,,"fee schedule","76484","99326",
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","82045",,,,,,,"fee schedule","76484","99326",
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","76484",,,,,,,"fee schedule","76484","99326",
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","31931.03","31931.03","31931.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","27357.84","27357.84","27357.84","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21082.92","21082.92","21082.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","45836",,,,,,,"fee schedule","45836","59523",
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","49167",,,,,,,"fee schedule","45836","59523",
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","59523",,,,,,,"fee schedule","45836","59523",
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","14608","14608","14608","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","17364.59","17364.59","17364.59","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","10872","10872","10872","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","11440.22","11440.22","11720.35","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","27692",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","26791",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","19755",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","24315",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24054",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","28921",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","20305",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","22270",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","19755",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","27013",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","24801",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","27692",,,,,,,"fee schedule","19755","28921",
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","38","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","75844",,,,,,,"fee schedule","53967","75844",
"Description Not Available","38","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","53967",,,,,,,"fee schedule","53967","75844",
"Description Not Available","38","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","68803",,,,,,,"fee schedule","53967","75844",
"Description Not Available","38","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","71209",,,,,,,"fee schedule","53967","75844",
"Description Not Available","38","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","63003",,,,,,,"fee schedule","53967","75844",
"Description Not Available","38","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","55607",,,,,,,"fee schedule","53967","75844",
"Description Not Available","38","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","72162",,,,,,,"fee schedule","53967","75844",
"Description Not Available","38","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","68803",,,,,,,"fee schedule","53967","75844",
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22841.26","22841.26","22841.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22219.12","22219.12","22219.12","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","27946",,,,,,,"fee schedule","27946","37554",
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","37554",,,,,,,"fee schedule","27946","37554",
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","30933",,,,,,,"fee schedule","27946","37554",
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18902",,,,,,,"fee schedule","18902","25400",
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","25400",,,,,,,"fee schedule","18902","25400",
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","20923",,,,,,,"fee schedule","18902","25400",
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","32281",,,,,,,"fee schedule","32281","43377",
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","43377",,,,,,,"fee schedule","32281","43377",
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","35730",,,,,,,"fee schedule","32281","43377",
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24302",,,,,,,"fee schedule","21956","29504",
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21956",,,,,,,"fee schedule","21956","29504",
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29504",,,,,,,"fee schedule","21956","29504",
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","62673",,,,,,,"fee schedule","48261","62673",
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","48261",,,,,,,"fee schedule","48261","62673",
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","51768",,,,,,,"fee schedule","48261","62673",
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","31169.54","31169.54","31169.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","39097",,,,,,,"fee schedule","30106","39097",
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","32295",,,,,,,"fee schedule","30106","39097",
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30106",,,,,,,"fee schedule","30106","39097",
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","29156","29156","29156","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","67417","67417","67417","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inflammatory Bowel Disease With Cc","386","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","30323",,,,,,,"fee schedule","28268","36710",
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","36710",,,,,,,"fee schedule","28268","36710",
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","28268",,,,,,,"fee schedule","28268","36710",
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","10376","10376","10376","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","44226",,,,,,,"fee schedule","39957","53693",
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","39957",,,,,,,"fee schedule","39957","53693",
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","53693",,,,,,,"fee schedule","39957","53693",
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21718",,,,,,,"fee schedule","21718","29183",
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24037",,,,,,,"fee schedule","21718","29183",
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29183",,,,,,,"fee schedule","21718","29183",
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","14884.17","14884.17","14884.17","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","19262","19262","19262","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","39","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","50725",,,,,,,"fee schedule","37665","53667",
"Description Not Available","39","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","37665",,,,,,,"fee schedule","37665","53667",
"Description Not Available","39","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","49698",,,,,,,"fee schedule","37665","53667",
"Description Not Available","39","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","53667",,,,,,,"fee schedule","37665","53667",
"Description Not Available","39","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","39088",,,,,,,"fee schedule","37665","53667",
"Description Not Available","39","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","44014",,,,,,,"fee schedule","37665","53667",
"Description Not Available","39","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","44284",,,,,,,"fee schedule","37665","53667",
"Description Not Available","39","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","44014",,,,,,,"fee schedule","37665","53667",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","21597",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","15830",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","17367",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","20889",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","22555",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","18676",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","15408",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","15408",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","21059",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","18964",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","19341",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","21597",,,,,,,"fee schedule","15408","22555",
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","15738.75","15738.75","15738.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","18523","18523","18523","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","31128","31128","31128","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","14875.63","14875.63","14875.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","19246.67","19246.67","19246.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]","26868","26868","26868","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","57786","57786","57786","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","15123.55","15123.55","15123.55","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","33480.49","33480.49","48190","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","45801","45801","51460","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","12271.91","12271.91","12271.91","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","79310","79310","79310","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","39235","39235","39235","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","86428",,,,,,,"fee schedule","66553","86428",
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","66553",,,,,,,"fee schedule","66553","86428",
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","71391",,,,,,,"fee schedule","66553","86428",
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","18303.53","18303.53","18303.53","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","9638","9638","9638","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","36553.01","36553.01","36553.01","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","37393.83","37393.83","37393.83","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","35959",,,,,,,"fee schedule","27690","35959",
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","27690",,,,,,,"fee schedule","27690","35959",
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","29703",,,,,,,"fee schedule","27690","35959",
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","19276","19276","19276","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","6997.46","6997.46","6997.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","27586",,,,,,,"fee schedule","25717","33396",
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","33396",,,,,,,"fee schedule","25717","33396",
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","25717",,,,,,,"fee schedule","25717","33396",
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","8674.2","8674.2","8674.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","6857.76","6857.76","6857.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","66048",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","75685",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","68028",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","51538",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","68003",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","58322",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","62383",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","38928",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","38928",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","70496",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","48431",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","66048",,,,,,,"fee schedule","38928","75685",
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","5429.25","5429.25","5429.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","52662",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","37379",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","49321",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","42274",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","54860",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","51099",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","45219",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","38928",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","57681",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","38928",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","52662",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","48431",,,,,,,"fee schedule","37379","57681",
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","45139.04","45139.04","45139.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","32955",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","30800",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","26963",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","35170",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","23342",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","31867",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","34154",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","26319",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28560",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","26963",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","33508",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","32955",,,,,,,"fee schedule","23342","35170",
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","11122.99","11122.99","11122.99","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","40","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","133092",,,,,,,"fee schedule","133092","193604",
"Description Not Available","40","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","172301",,,,,,,"fee schedule","133092","193604",
"Description Not Available","40","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","193604",,,,,,,"fee schedule","133092","193604",
"Description Not Available","40","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","175616",,,,,,,"fee schedule","133092","193604",
"Description Not Available","40","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","159440",,,,,,,"fee schedule","133092","193604",
"Description Not Available","40","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","149075",,,,,,,"fee schedule","133092","193604",
"Description Not Available","40","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","171408",,,,,,,"fee schedule","133092","193604",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","205376",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","242289",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","159972",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","211083",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","242289",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","165235",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","187215",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","214430",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","222154",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","219136",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","214636",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","205376",,,,,,,"fee schedule","159972","242289",
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","137393",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","210500",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","164591",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","199861",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","181290",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","182990",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","153894",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","177868",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","183428",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","210500",,,,,,,"fee schedule","137393","210500",
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","73375.89","73375.89","73375.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","56306.97","56306.97","56306.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","164578.6","164578.6","164578.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","60765.46","60765.46","60765.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","62165.71","62165.71","62165.71","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","140647.94","140647.94","140647.94","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","175110","175110","175110","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","62123.16","62123.16","62123.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","96123",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","83552",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","62734",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","82780",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","81213",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","70274",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","75158",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","91264",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","83753",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","96123",,,,,,,"fee schedule","62734","96123",
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","51431.41","51431.41","51431.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","72785","72785","72785","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","62248",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","48673",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","54115",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","40632",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","53611",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","59102",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","45507",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","52601",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","54246",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","62248",,,,,,,"fee schedule","40632","62248",
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","57236","57236","57236","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","99008",,,,,,,"fee schedule","99008","133042",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","109585",,,,,,,"fee schedule","99008","133042",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","133042",,,,,,,"fee schedule","99008","133042",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","52048",,,,,,,"fee schedule","52048","69942",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","57610",,,,,,,"fee schedule","52048","69942",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","69942",,,,,,,"fee schedule","52048","69942",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","24227.07","24227.07","24227.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","41","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","103382",,,,,,,"fee schedule","78349","111025",
"Description Not Available","41","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","104919",,,,,,,"fee schedule","78349","111025",
"Description Not Available","41","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","78349",,,,,,,"fee schedule","78349","111025",
"Description Not Available","41","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","109414",,,,,,,"fee schedule","78349","111025",
"Description Not Available","41","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","80849",,,,,,,"fee schedule","78349","111025",
"Description Not Available","41","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","91604",,,,,,,"fee schedule","78349","111025",
"Description Not Available","41","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","111025",,,,,,,"fee schedule","78349","111025",
"Description Not Available","41","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","111025",,,,,,,"fee schedule","78349","111025",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","38570",,,,,,,"fee schedule","38570","51827",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","42691",,,,,,,"fee schedule","38570","51827",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","51827",,,,,,,"fee schedule","38570","51827",
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","56011",,,,,,,"fee schedule","56011","75265",
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","61994",,,,,,,"fee schedule","56011","75265",
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","75265",,,,,,,"fee schedule","56011","75265",
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","47115",,,,,,,"fee schedule","42569","57201",
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","42569",,,,,,,"fee schedule","42569","57201",
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","57201",,,,,,,"fee schedule","42569","57201",
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","89230",,,,,,,"fee schedule","89230","119906",
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","119906",,,,,,,"fee schedule","89230","119906",
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","98764",,,,,,,"fee schedule","89230","119906",
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","49964",,,,,,,"fee schedule","49964","67143",
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","55305",,,,,,,"fee schedule","49964","67143",
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","67143",,,,,,,"fee schedule","49964","67143",
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","38717",,,,,,,"fee schedule","34977","47003",
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","47003",,,,,,,"fee schedule","34977","47003",
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","34977",,,,,,,"fee schedule","34977","47003",
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","65614",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","52468",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","48557",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","61359",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","56122",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","46502",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","68090",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","71801",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","48557",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","63465",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","60258",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","65614",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","65614",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","61359",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","56122",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","46502",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","71801",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","68090",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","52468",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","48557",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","48557",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","63465",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","60258",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","65614",,,,,,,"fee schedule","46502","71801",
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","56515.86","56515.86","56515.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","19371.08","19371.08","19371.08","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","34218",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","36503",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","40134",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","25930",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","31276",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","29240",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","37945",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","27059",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","35466",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","27059",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","33593",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","36503",,,,,,,"fee schedule","25930","40134",
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","32179","32179","32179","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","42","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","76597",,,,,,,"fee schedule","58050","84955",
"Description Not Available","42","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","70025",,,,,,,"fee schedule","58050","84955",
"Description Not Available","42","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","65403",,,,,,,"fee schedule","58050","84955",
"Description Not Available","42","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","58050",,,,,,,"fee schedule","58050","84955",
"Description Not Available","42","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","84955",,,,,,,"fee schedule","58050","84955",
"Description Not Available","42","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","65403",,,,,,,"fee schedule","58050","84955",
"Description Not Available","42","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","65465",,,,,,,"fee schedule","58050","84955",
"Description Not Available","42","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","82374",,,,,,,"fee schedule","58050","84955",
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","22417.83","22417.83","22417.83","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","10132","10132","10132","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]","62111.3","62111.3","62111.3","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","66697",,,,,,,"fee schedule","60258","80973",
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","60258",,,,,,,"fee schedule","60258","80973",
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","80973",,,,,,,"fee schedule","60258","80973",
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","34014.13","34014.13","34014.13","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","24230.87","24230.87","24230.87","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","37941",,,,,,,"fee schedule","37941","50983",
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","41994",,,,,,,"fee schedule","37941","50983",
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","50983",,,,,,,"fee schedule","37941","50983",
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","326648",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","305369",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","231427",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","280063",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","357388",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","261827",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","339778",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","242289",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","242289",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","316852",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","300262",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","326648",,,,,,,"fee schedule","231427","357388",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","226883",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","242289",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","175886",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","232081",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","248038",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","206945",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","237030",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","182650",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","242289",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","242086",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","229411",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","226883",,,,,,,"fee schedule","175886","248038",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","191487",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","207620",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","159987",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","181268",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","222938",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","147798",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","195021",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","222938",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","206719",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","202172",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","210183",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","191487",,,,,,,"fee schedule","147798","222938",
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","326648",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","231427",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","280063",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","242289",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","357388",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","261827",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","339778",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","305369",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","242289",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","316852",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","326648",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","300262",,,,,,,"fee schedule","231427","357388",
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","212809",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","165472",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","218340",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","194107",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","227068",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","222325",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","171319",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","242289",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","242289",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","231099",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","219797",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","212809",,,,,,,"fee schedule","165472","242289",
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","114679.98","114679.98","114679.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","21912","21912","29216","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","408612","408612","408612","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21567.72","21567.72","22752.76","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","133796","61752","231866.83","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","108720","108720","108720","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","12546.28","12546.28","12546.28","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","35226","35226","35226","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22290.06","22290.06","22290.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","40106.6","28914","57828","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","14608","14608","14608","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","45992.29","45992.29","45992.29","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","38552","38552","38552","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","23793","23793","23793","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","44053.19","44053.19","44053.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21155.24","21155.24","21155.24","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","14399","14399","14399","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","30876","30876","61752","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","41504","41504","41504","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","12521.02","12521.02","12521.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","33809.04","33809.04","33809.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","31724","31724","31724","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","12521.02","12521.02","12521.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","10292","10292","10292","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","55517","55517","55517","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","25256",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","18468",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","24369",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","20310",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","21814",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","26377",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","18002",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","24571",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","18002",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","22174",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","22617",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","25256",,,,,,,"fee schedule","18002","26377",
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","57828","57828","57828","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","87480","87480","87480","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","9280.04","9280.04","9280.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","873.95","873.95","873.95","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","48190","48190","48190","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","11241.54","11241.54","11241.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","27870",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","26942",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24054",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","22411",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","20419",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29104",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","27166",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","19908",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","19908",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","24472",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","24958",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","27870",,,,,,,"fee schedule","19908","29104",
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","23826","23826","23826","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","20844.02","20844.02","20844.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","38397.95","38397.95","38397.95","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","41168","41168","41168","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","19571.31","19571.31","19571.31","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","26500",,,,,,,"fee schedule","26500","35609",
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","29330",,,,,,,"fee schedule","26500","35609",
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","35609",,,,,,,"fee schedule","26500","35609",
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","38552","38552","38552","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","19451.63","19451.63","19451.63","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","12838.34","12838.34","12838.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","22857",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","23691",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","16933",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","20470",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","17322",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","24740",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19048",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","23045",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","16933",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","20797",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","23691",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","21212",,,,,,,"fee schedule","16933","24740",
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","20250","20250","20250","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","199517",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","194823",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","170324",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","192725",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","185999",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","245428",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","159233",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","206643",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","194823",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","287303",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","182680",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","199517",,,,,,,"fee schedule","159233","287303",
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","149464",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","127965",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","144475",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","190635",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","155251",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","119635",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","199890",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","199890",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","206516",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","144893",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","137260",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","149464",,,,,,,"fee schedule","119635","206516",
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","199517",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","170324",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","185330",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","176915",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","273285",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","233440",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","159233",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","206643",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","185330",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","242376",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","182680",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","199517",,,,,,,"fee schedule","159233","273285",
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","154261",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","110394",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","155251",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","145665",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","119635",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","127965",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","122400",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","122400",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","168567",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","151307",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","137260",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","154261",,,,,,,"fee schedule","110394","168567",
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","207660","207660","207660","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","20000","20000","20000","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","44755.18","44755.18","44755.18","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","97566.49","97566.49","99272.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","214538","214538","214538","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","44907.11","44907.11","44907.11","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","202272",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","266899",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","285534",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","228907",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","211830",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","297060",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","312613",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","244853",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","211830",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","276954",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","262508",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","285534",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","285534",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","228907",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","211830",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","202272",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","266899",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","297060",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","312613",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","244853",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","211830",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","276954",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","262508",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","285534",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]","2135","2135","2135","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","285534",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","202272",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","266899",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","297060",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","312613",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","244853",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","211830",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","228907",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","211830",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","276954",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","262508",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","285534",,,,,,,"fee schedule","202272","312613",
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","192725",,,,,,,"fee schedule","192725","192725",
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","144893",,,,,,,"fee schedule","144893","144893",
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","149768","149768","149768","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","36158.06","36158.06","36158.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","155704",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","110349",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","115653",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","151191",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","145606",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","133685",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","115653",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","124983",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","162193",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","170626",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","143423",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","155704",,,,,,,"fee schedule","110349","170626",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","114655",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","141236",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","119953",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","115653",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","107038",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","92432",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","104725",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","115653",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","146444",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","153323",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","138918",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","114655",,,,,,,"fee schedule","92432","153323",
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","180007",,,,,,,"fee schedule","180007","233762",
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","193092",,,,,,,"fee schedule","180007","233762",
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","233762",,,,,,,"fee schedule","180007","233762",
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","555685.75","555685.75","555685.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","72890",,,,,,,"fee schedule","67950","88243",
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","67950",,,,,,,"fee schedule","67950","88243",
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","88243",,,,,,,"fee schedule","67950","88243",
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","103897",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","80963",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","83563",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","94681",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","106830",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","94167",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","110803",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","108443",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","94167",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","115257",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","104925",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","103897",,,,,,,"fee schedule","80963","115257",
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","127067",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","118701",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","138961",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","94167",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","123191",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","89961",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","101756",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","108844",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","132051",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","94167",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","116658",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","127067",,,,,,,"fee schedule","89961","138961",
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","75566",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","96922",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","94167",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","99709",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","77954",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","101162",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","88323",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","106866",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","94167",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","103363",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","97882",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","96922",,,,,,,"fee schedule","75566","106866",
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","65482",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","100276",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","74375",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","109518",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","86405",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","80367",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","74375",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","85968",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","104296",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","97296",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","92215",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","100276",,,,,,,"fee schedule","65482","109518",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","85783",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","78238",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","95390",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","74375",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","91557",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","61555",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","81223",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","69052",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","89610",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","74375",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","86774",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","85783",,,,,,,"fee schedule","61555","95390",
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","87723",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","112033",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","117111",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","115751",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","100815",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","90243",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","102247",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","100815",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","124619",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","119602",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","124929",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","112033",,,,,,,"fee schedule","87723","124929",
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","88899",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","100815",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","91582",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","69407",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","71609",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","81134",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","100815",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","92930",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","96735",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","94905",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","93697",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","88899",,,,,,,"fee schedule","69407","100815",
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","86126","86126","86126","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","38883.65","38883.65","38883.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","68047",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","53237",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","70246",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","62084",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","54795",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","67876",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","71109",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","67876",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","74844",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","72540",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","68047",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","84129",,,,,,,"fee schedule","53237","84129",
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","65413.68","65413.68","65413.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","32643.45","32643.45","32643.45","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","107535",,,,,,,"fee schedule","107535","144501",
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","144501",,,,,,,"fee schedule","107535","144501",
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","119023",,,,,,,"fee schedule","107535","144501",
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","64132",,,,,,,"fee schedule","57942","77861",
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","77861",,,,,,,"fee schedule","57942","77861",
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","57942",,,,,,,"fee schedule","57942","77861",
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","38345",,,,,,,"fee schedule","28536","38345",
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","28536",,,,,,,"fee schedule","28536","38345",
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","31585",,,,,,,"fee schedule","28536","38345",
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","100912",,,,,,,"fee schedule","75097","100912",
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","83119",,,,,,,"fee schedule","75097","100912",
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","75097",,,,,,,"fee schedule","75097","100912",
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","58360",,,,,,,"fee schedule","52728","70854",
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","70854",,,,,,,"fee schedule","52728","70854",
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","52728",,,,,,,"fee schedule","52728","70854",
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","44778",,,,,,,"fee schedule","40455","54363",
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","40455",,,,,,,"fee schedule","40455","54363",
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","54363",,,,,,,"fee schedule","40455","54363",
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","96113",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","93326",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","68141",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","89913",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","77027",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","99959",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","82392",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","71280",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","71280",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","105280",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","88273",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","96113",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","96113",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","68141",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","89913",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","77027",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","71280",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","82392",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","99959",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","71280",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","105280",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","93326",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","88273",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","96113",,,,,,,"fee schedule","68141","105280",
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","64454",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","67002",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","62531",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","47767",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","45785",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","60414",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","47767",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","51630",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","55228",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","70792",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","59293",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","64454",,,,,,,"fee schedule","45785","70792",
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","87325",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","61701",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","81415",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","70010",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","90854",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","64789",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","74889",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","64789",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","95597",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","84697",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","80302",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","87325",,,,,,,"fee schedule","61701","95597",
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","92809",,,,,,,"fee schedule","83852","112677",
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","112677",,,,,,,"fee schedule","83852","112677",
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","83852",,,,,,,"fee schedule","83852","112677",
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","58507",,,,,,,"fee schedule","52861","71032",
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","52861",,,,,,,"fee schedule","52861","71032",
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","71032",,,,,,,"fee schedule","52861","71032",
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","54204",,,,,,,"fee schedule","40336","54204",
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","40336",,,,,,,"fee schedule","40336","54204",
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","44647",,,,,,,"fee schedule","40336","54204",
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","39113",,,,,,,"fee schedule","35338","47485",
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","47485",,,,,,,"fee schedule","35338","47485",
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","35338",,,,,,,"fee schedule","35338","47485",
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","33814",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","32578",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","27190",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","23647",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","24690",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","29309",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","35312",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","23647",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","32200",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","29686",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","33814",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","29787",,,,,,,"fee schedule","23647","35312",
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","80616",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","64496",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","68989",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","59683",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","56872",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","75043",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","83696",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","59683",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","87733",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","77929",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","73913",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","80616",,,,,,,"fee schedule","56872","87733",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","52218",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","39251",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","37023",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","48853",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","41773",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","54209",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","44682",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","39251",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","57075",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","50632",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","47918",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","52218",,,,,,,"fee schedule","37023","57075",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","35025",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","27455",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30901",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","22110",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","36227",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33049",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40100",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","22110",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","36161",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","37409",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","27442",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","35025",,,,,,,"fee schedule","22110","40100",
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","91489",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","67876",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","64920",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","85663",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","73353",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","100037",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","78461",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","95191",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","67876",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","88663",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","84129",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","91489",,,,,,,"fee schedule","64920","100037",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","74473",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","77097",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","58430",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","82572",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","59969",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","77823",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","67946",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","67876",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","67876",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","79389",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","75330",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","74473",,,,,,,"fee schedule","58430","82572",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","32729",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","46212",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","34166",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","43185",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","36926",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","50220",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","39498",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","47920",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","34166",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","44567",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","46212",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","42273",,,,,,,"fee schedule","32729","50220",
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","61908",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","57817",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","43815",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","64403",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","67767",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","59963",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","53081",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","49629",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","45933",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","45933",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","56935",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","61908",,,,,,,"fee schedule","43815","67767",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","41626",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","53245",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","42869",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","48568",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","59368",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","54926",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","45933",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","55633",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","45933",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","56731",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","53865",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","53245",,,,,,,"fee schedule","41626","59368",
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","54064",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","35284",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","46995",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","46558",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","39524",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","42273",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","51330",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","45679",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","47105",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","54064",,,,,,,"fee schedule","35284","54064",
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","43784","43784","43784","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","38373",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","25048",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","32426",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","33359",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","33052",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","36433",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","28055",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","30004",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","33438",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","38373",,,,,,,"fee schedule","25048","38373",
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","57744",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","62724",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","59844",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","53807",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","55764",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","40778",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","49328",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","42678",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","46115",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","42678",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","52860",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","57744",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","38066.89","38066.89","38066.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","53807",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","57744",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","59844",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","55764",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","49328",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","42678",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","40778",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","46115",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","42678",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","62724",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","52860",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","57744",,,,,,,"fee schedule","40778","62724",
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","35884",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","46311",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","42678",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","50945",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","49196",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","47348",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","48203",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","37145",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","42088",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","42678",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","46634",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","46311",,,,,,,"fee schedule","35884","50945",
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","50613",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","51795",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","53069",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","46333",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","44376",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","39253",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","40894",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","44376",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","54264",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","56459",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","51407",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","50613",,,,,,,"fee schedule","39253","56459",
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","54980",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","51209",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","38810",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","47184",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","44112",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","57245",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","40826",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","40826",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","60104",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","53431",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","50586",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","54980",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","54980",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","38810",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","51209",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","44112",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","40826",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","57245",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","47184",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","60104",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","40826",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","53431",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","50586",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","54980",,,,,,,"fee schedule","38810","60104",
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","58415",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","55419",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","28452",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","62517",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","60223",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","45641",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","51807",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","67232",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","28452",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","66382",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","56651",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","58415",,,,,,,"fee schedule","28452","67232",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","47394",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","46187",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","35919",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","40961",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","28452",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","43816",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","28452",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","53157",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","47596",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","49430",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","44791",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","46187",,,,,,,"fee schedule","28452","53157",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","40648",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","32772",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","38130",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","28897",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","39547",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","28452",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","41747",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","35057",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","42529",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","28452",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","36943",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","40648",,,,,,,"fee schedule","28452","42529",
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","38617",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","36512",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","27829",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","40086",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","30379",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","27829",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","34136",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","44300",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","40942",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","41316",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","38592",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","38617",,,,,,,"fee schedule","27829","44300",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","37422",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30074",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","26649",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","27829",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","35165",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","32169",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","39029",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","27829",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","40942",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","36400",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","34561",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","37422",,,,,,,"fee schedule","26649","40942",
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","77237",,,,,,,"fee schedule","77237","103790",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","103790",,,,,,,"fee schedule","77237","103790",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","85488",,,,,,,"fee schedule","77237","103790",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","32287.39","32287.39","32287.39","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","52625",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","49964",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","45744",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","34347",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","45321",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","41149",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","38473",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","44465",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","45855",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","52625",,,,,,,"fee schedule","34347","52625",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","250","250","250","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","28681",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","33308",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","21736",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","24351",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","26044",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","28951",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","28140",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","31624",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","29020",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","33308",,,,,,,"fee schedule","21736","33308",
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","70929",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","50256",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","56810",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","73721",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","60764",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","66312",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","50417",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","68836",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","50417",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","77851",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","65230",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","70929",,,,,,,"fee schedule","50256","77851",
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","61257",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","68511",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","65394",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","47742",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","62996",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","50417",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","50417",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","53970",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","70038",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","57729",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","61971",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","61257",,,,,,,"fee schedule","47742","70038",
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]","62668","62668","62668","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","46663",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","33028",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","50825",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","43657",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","33086",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","33028",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","37260",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","39857",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","48354",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","45030",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","42723",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","46663",,,,,,,"fee schedule","33028","50825",
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","54178",,,,,,,"fee schedule","48948","65777",
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","65777",,,,,,,"fee schedule","48948","65777",
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","48948",,,,,,,"fee schedule","48948","65777",
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","38550",,,,,,,"fee schedule","34830","46802",
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","34830",,,,,,,"fee schedule","34830","46802",
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","46802",,,,,,,"fee schedule","34830","46802",
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","15643",,,,,,,"fee schedule","14133","18992",
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","14133",,,,,,,"fee schedule","14133","18992",
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","18992",,,,,,,"fee schedule","14133","18992",
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30318",,,,,,,"fee schedule","30318","40740",
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33556",,,,,,,"fee schedule","30318","40740",
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40740",,,,,,,"fee schedule","30318","40740",
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","27358",,,,,,,"fee schedule","20359","27358",
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","22533",,,,,,,"fee schedule","20359","27358",
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","20359",,,,,,,"fee schedule","20359","27358",
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","45676",,,,,,,"fee schedule","42580","55297",
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","42580",,,,,,,"fee schedule","42580","55297",
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","55297",,,,,,,"fee schedule","42580","55297",
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","35451",,,,,,,"fee schedule","35451","46037",
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","38028",,,,,,,"fee schedule","35451","46037",
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","46037",,,,,,,"fee schedule","35451","46037",
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","47704",,,,,,,"fee schedule","44471","57752",
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","57752",,,,,,,"fee schedule","44471","57752",
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","44471",,,,,,,"fee schedule","44471","57752",
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","45070",,,,,,,"fee schedule","45070","58530",
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","48347",,,,,,,"fee schedule","45070","58530",
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","58530",,,,,,,"fee schedule","45070","58530",
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","7869.85","7869.85","7869.85","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","23793","23793","23793","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","15862","15862","15862","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","10292","10292","10292","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","24559",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","17544",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","21562",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","25647",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","18010",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","23764",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","21366",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19746",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","17544",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","23958",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","21994",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","24559",,,,,,,"fee schedule","17544","25647",
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","23656.58","23656.58","23656.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","13622.31","13622.31","13622.31","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","18444.07","18444.07","18444.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","19733",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","26996",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21708",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","23305",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","26038",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","28195",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","19298",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","19298",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","23707",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","26250",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","24176",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","26996",,,,,,,"fee schedule","19298","28195",
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","45873",,,,,,,"fee schedule","45873","61644",
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","50776",,,,,,,"fee schedule","45873","61644",
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","61644",,,,,,,"fee schedule","45873","61644",
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","28823",,,,,,,"fee schedule","21450","28823",
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","23742",,,,,,,"fee schedule","21450","28823",
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21450",,,,,,,"fee schedule","21450","28823",
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","28914","28914","28914","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","79750",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","92596",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","87915",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","60439",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","67694",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","72401",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","80496",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","78244",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","80692",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","92596",,,,,,,"fee schedule","60439","92596",
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","29783.8","29783.8","29783.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","54208",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","35379",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","51468",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","46684",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","45802",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","39630",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","42385",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","47119",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","47233",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","54208",,,,,,,"fee schedule","35379","54208",
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","58823",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","38394",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","50661",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","43006",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","55849",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","45993",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","51135",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","49703",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","51258",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","58823",,,,,,,"fee schedule","38394","58823",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","62830",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","54108",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","53604",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","40625",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","59654",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","45933",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","49127",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","68747",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","68830",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","62830",,,,,,,"fee schedule","40625","68830",
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","61975",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","41699",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","55022",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","48459",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","58843",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","45308",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","55538",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","56142",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","61975",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","55299",,,,,,,"fee schedule","41699","61975",
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","50163",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","76784",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","66190",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","56136",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","60037",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","66809",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","72903",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","67463",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","67547",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","76784",,,,,,,"fee schedule","50163","76784",
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","59804",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","43721",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","38669",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","51021",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","56782",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","46761",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","51501",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","52065",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","50003",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","59804",,,,,,,"fee schedule","38669","59804",
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","51560",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","68033",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","79743",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","75712",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","69029",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","58299",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","62350",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","68670",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","69115",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","79743",,,,,,,"fee schedule","51560","79743",
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","67870",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","53068",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","64440",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","43884",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","57904",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","58448",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","49618",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","59098",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","58209",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","67870",,,,,,,"fee schedule","43884","67870",
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40436",,,,,,,"fee schedule","30092","40436",
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30092",,,,,,,"fee schedule","30092","40436",
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33305",,,,,,,"fee schedule","30092","40436",
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","20069",,,,,,,"fee schedule","20069","26966",
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","22211",,,,,,,"fee schedule","20069","26966",
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","26966",,,,,,,"fee schedule","20069","26966",
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22454.67","22454.67","22454.67","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","23864",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","23005",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","20767",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","24919",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","17436",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","23197",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19188",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","17011",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","17011",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","20951",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","21368",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","23864",,,,,,,"fee schedule","17011","24919",
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","6985.23","6985.23","6985.23","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","27752","27752","27752","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","22402","22402","22402","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","22230",,,,,,,"fee schedule","22230","29871",
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29871",,,,,,,"fee schedule","22230","29871",
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24606",,,,,,,"fee schedule","22230","29871",
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","20369",,,,,,,"fee schedule","20369","27371",
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","27371",,,,,,,"fee schedule","20369","27371",
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","22544",,,,,,,"fee schedule","20369","27371",
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","61","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","99745",,,,,,,"fee schedule","85487","111023",
"Description Not Available","61","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","111023",,,,,,,"fee schedule","85487","111023",
"Description Not Available","61","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","85487",,,,,,,"fee schedule","85487","111023",
"Description Not Available","61","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","91432",,,,,,,"fee schedule","85487","111023",
"Description Not Available","61","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","99227",,,,,,,"fee schedule","85487","111023",
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","58770",,,,,,,"fee schedule","58770","78973",
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","65049",,,,,,,"fee schedule","58770","78973",
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","78973",,,,,,,"fee schedule","58770","78973",
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","81200","81200","81200","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","37853",,,,,,,"fee schedule","28170","37853",
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","28170",,,,,,,"fee schedule","28170","37853",
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","31179",,,,,,,"fee schedule","28170","37853",
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","60099",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","51759",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","39226",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","46993",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","57063",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","43938",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","52243",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","50781",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","60099",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","52370",,,,,,,"fee schedule","39226","60099",
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22364.09","22364.09","22364.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","62","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","60202",,,,,,,"fee schedule","56288","73102",
"Description Not Available","62","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","73102",,,,,,,"fee schedule","56288","73102",
"Description Not Available","62","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","56288",,,,,,,"fee schedule","56288","73102",
"Description Not Available","62","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","65333",,,,,,,"fee schedule","56288","73102",
"Description Not Available","62","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","65673",,,,,,,"fee schedule","56288","73102",
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","25424","25424","25424","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","21044.7","21044.7","21044.7","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","26288","26288","26288","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","20258","20258","20258","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","21671","21671","21671","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","88902",,,,,,,"fee schedule","88902","119464",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","119464",,,,,,,"fee schedule","88902","119464",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","98400",,,,,,,"fee schedule","88902","119464",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","46026",,,,,,,"fee schedule","46026","61848",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","50941",,,,,,,"fee schedule","46026","61848",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","61848",,,,,,,"fee schedule","46026","61848",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","27026",,,,,,,"fee schedule","27026","36317",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","29912",,,,,,,"fee schedule","27026","36317",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","36317",,,,,,,"fee schedule","27026","36317",
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","37735",,,,,,,"fee schedule","29057","37735",
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","29057",,,,,,,"fee schedule","29057","37735",
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","31170",,,,,,,"fee schedule","29057","37735",
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","62416.71","62416.71","62416.71","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","16901.22","16901.22","16901.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","26201",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","26587",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","25307",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","20980",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","27683",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","16172",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23179",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24917",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","30101",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","16172",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","24756",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","26201",,,,,,,"fee schedule","16172","30101",
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","25676","25676","25676","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","90488",,,,,,,"fee schedule","90488","121593",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","100154",,,,,,,"fee schedule","90488","121593",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","121593",,,,,,,"fee schedule","90488","121593",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","57679",,,,,,,"fee schedule","57679","77506",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","63840",,,,,,,"fee schedule","57679","77506",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","77506",,,,,,,"fee schedule","57679","77506",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","63","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","37901",,,,,,,"fee schedule","37901","49221",
"Description Not Available","63","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","44224",,,,,,,"fee schedule","37901","49221",
"Description Not Available","63","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","49221",,,,,,,"fee schedule","37901","49221",
"Description Not Available","63","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","40535",,,,,,,"fee schedule","37901","49221",
"Description Not Available","63","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","43993",,,,,,,"fee schedule","37901","49221",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","27899",,,,,,,"fee schedule","25206","33872",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","33872",,,,,,,"fee schedule","25206","33872",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","25206",,,,,,,"fee schedule","25206","33872",
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","31724","31724","31724","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","57659",,,,,,,"fee schedule","44400","57659",
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","47628",,,,,,,"fee schedule","44400","57659",
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","44400",,,,,,,"fee schedule","44400","57659",
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","9769.58","9769.58","9769.58","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","7456.37","7456.37","7456.37","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Diabetes With Cc","638","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","21775",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","21041",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","18823",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","22736",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","15560",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","17507",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","15946",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","15560",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","21212",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","19115",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","19495",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","21775",,,,,,,"fee schedule","15560","22736",
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","64","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","98880",,,,,,,"fee schedule","98880","128409",
"Description Not Available","64","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","106068",,,,,,,"fee schedule","98880","128409",
"Description Not Available","64","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","128409",,,,,,,"fee schedule","98880","128409",
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","64839",,,,,,,"fee schedule","64839","84201",
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","84201",,,,,,,"fee schedule","64839","84201",
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","69552",,,,,,,"fee schedule","64839","84201",
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","27640.07","27640.07","27640.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","34981.48","34981.48","34981.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","38574",,,,,,,"fee schedule","38574","50093",
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","41378",,,,,,,"fee schedule","38574","50093",
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","50093",,,,,,,"fee schedule","38574","50093",
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","11075.95","11075.95","11075.95","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","23632.26","23632.26","23632.26","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","9375.98","9375.98","9375.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","65","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","53822",,,,,,,"fee schedule","50175","65159",
"Description Not Available","65","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","65159",,,,,,,"fee schedule","50175","65159",
"Description Not Available","65","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","50175",,,,,,,"fee schedule","50175","65159",
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","218800.31","218800.31","218800.31","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","115934.65","115934.65","115934.65","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","66086.82","66086.82","66086.82","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","108364.41","108364.41","108364.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","196642.9","196642.9","196642.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","63749.97","63749.97","63749.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Bladder Procedures With Mcc","653","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","57786","57786","57786","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Bladder Procedures With Cc","654","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","55393.21","55393.21","55393.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","129653",,,,,,,"fee schedule","129653","168372",
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","168372",,,,,,,"fee schedule","129653","168372",
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","139078",,,,,,,"fee schedule","129653","168372",
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","38301",,,,,,,"fee schedule","34603","46500",
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","34603",,,,,,,"fee schedule","34603","46500",
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","46500",,,,,,,"fee schedule","34603","46500",
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21269.75","21269.75","21269.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","32616","32616","32616","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","47089",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","41653",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","49950",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","37856",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","54096",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","44826",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","27993",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","27993",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","47309",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","45477",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","45179",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","47089",,,,,,,"fee schedule","27993","54096",
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","17709.99","17709.99","17709.99","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","85446",,,,,,,"fee schedule","85446","110961",
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","110961",,,,,,,"fee schedule","85446","110961",
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","91656",,,,,,,"fee schedule","85446","110961",
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","82748","82748","82748","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","66","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","36894",,,,,,,"fee schedule","28410","36894",
"Description Not Available","66","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","28410",,,,,,,"fee schedule","28410","36894",
"Description Not Available","66","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","30475",,,,,,,"fee schedule","28410","36894",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","44090",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","37970",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","28775",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","32234",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","41863",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","34474",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","38324",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","37251",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","38417",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","44090",,,,,,,"fee schedule","28775","44090",
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","42806","42806","42806","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","30118.87","30118.87","30118.87","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","39185",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","28771",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","36885",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33939",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40919",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","37964",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","31508",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","25477",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","25477",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","34405",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","39185",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","34524",,,,,,,"fee schedule","25477","40919",
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","32739.95","32739.95","32739.95","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","43539",,,,,,,"fee schedule","39337","52860",
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","39337",,,,,,,"fee schedule","39337","52860",
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","52860",,,,,,,"fee schedule","39337","52860",
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","29114",,,,,,,"fee schedule","29114","39122",
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","39122",,,,,,,"fee schedule","29114","39122",
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","32224",,,,,,,"fee schedule","29114","39122",
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","31610",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","20634",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","27226",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","27481",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24716",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","30013",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23109",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","26711",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","27548",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","31610",,,,,,,"fee schedule","20634","31610",
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","67","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","47119",,,,,,,"fee schedule","35065","47119",
"Description Not Available","67","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","35065",,,,,,,"fee schedule","35065","47119",
"Description Not Available","67","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","38811",,,,,,,"fee schedule","35065","47119",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","22644",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","16172",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","21795",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","16519",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","19575",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18209",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","23648",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","16172",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","21974",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","19882",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","22644",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","20276",,,,,,,"fee schedule","16172","23648",
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","30876","30876","30876","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","172634","172634","172634","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","58609",,,,,,,"fee schedule","58609","78757",
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","64872",,,,,,,"fee schedule","58609","78757",
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","78757",,,,,,,"fee schedule","58609","78757",
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","68","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29376",,,,,,,"fee schedule","21860","29376",
"Description Not Available","68","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21860",,,,,,,"fee schedule","21860","29376",
"Description Not Available","68","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24196",,,,,,,"fee schedule","21860","29376",
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","96215",,,,,,,"fee schedule","74088","96215",
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","74088",,,,,,,"fee schedule","74088","96215",
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","79475",,,,,,,"fee schedule","74088","96215",
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","12305.41","12305.41","12305.41","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22429.05","22429.05","35218.13","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","76104","76104","76104","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","47701",,,,,,,"fee schedule","44469","57749",
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","57749",,,,,,,"fee schedule","44469","57749",
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","44469",,,,,,,"fee schedule","44469","57749",
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","14179.77","14179.77","14179.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","27870",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","22411",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29104",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","26942",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","20419",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","27166",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24205",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","19908",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","19908",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","24472",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","24958",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","27870",,,,,,,"fee schedule","19908","29104",
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","43197","43197","43197","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","9631","9631","9631","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","69","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","17544",,,,,,,"fee schedule","17544","25647",
"Description Not Available","69","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","18010",,,,,,,"fee schedule","17544","25647",
"Description Not Available","69","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","23764",,,,,,,"fee schedule","17544","25647",
"Description Not Available","69","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","17544",,,,,,,"fee schedule","17544","25647",
"Description Not Available","69","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","25647",,,,,,,"fee schedule","17544","25647",
"Description Not Available","69","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","19746",,,,,,,"fee schedule","17544","25647",
"Description Not Available","69","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","21217",,,,,,,"fee schedule","17544","25647",
"Description Not Available","69","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","23958",,,,,,,"fee schedule","17544","25647",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","26476",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","25581",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","19386",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","25792",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","23008",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21290",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","27649",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","18917",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","18917",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","23245",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","23708",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","26476",,,,,,,"fee schedule","18917","27649",
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","18975","18975","18975","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","8294.34","8294.34","8294.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","19159",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","13995",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","13652",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","18466",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","15405",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","20006",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","16585",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","13652",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","18619",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","16820",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","17158",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","19159",,,,,,,"fee schedule","13652","20006",
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","17945.02","17945.02","17945.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","15862","15862","15862","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","23128.16","23128.16","23128.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","10376","10376","10376","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","19276","19276","19276","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","7931","7931","7931","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","12110.86","12110.86","12110.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","21744","21744","21744","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","44693",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","41969",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","37124",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","33872",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","48212",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","42167",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","39998",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","24867",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","24867",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","40534",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","40267",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","41969",,,,,,,"fee schedule","24867","48212",
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","42031","42031","42031","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21014.93","21014.93","21014.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","46632",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","40166",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","30441",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","40543",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","36462",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","39407",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","34091",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","44275",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","40639",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","46632",,,,,,,"fee schedule","30441","46632",
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","16515",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","20598",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","21790",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","19791",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18217",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","23658",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","13652",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","13652",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","20480",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","19892",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","19760",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","20598",,,,,,,"fee schedule","13652","23658",
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","68693",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","44832",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","65221",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","59156",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","50219",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","53710",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","59711",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","58042",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","59857",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","68693",,,,,,,"fee schedule","44832","68693",
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","56355",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","41200",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","47618",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","36781",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","48534",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","44064",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","53507",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","48986",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","49107",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","56355",,,,,,,"fee schedule","36781","56355",
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","57596","57596","57596","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","28738",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","20994",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","30013",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","20520",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","27700",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","25232",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23109",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24801",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","20520",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","27926",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","25734",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","28738",,,,,,,"fee schedule","20520","30013",
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","86472",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","56437",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","63217",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","74468",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","67611",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","75168",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","82101",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","73062",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","75348",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","86472",,,,,,,"fee schedule","56437","86472",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","39710",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","42259",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","35123",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","37890",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","32026",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","45614",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","22119",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","38349",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","22119",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","41173",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","37514",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","39710",,,,,,,"fee schedule","22119","45614",
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","58432","58432","58432","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","69678",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","60013",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","45482",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","60575",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","50940",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","54483",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","66156",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","58881",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","60720",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","69678",,,,,,,"fee schedule","45482","69678",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","67649","67649","67649","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","33965",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","24893",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","35471",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","24256",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","32847",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","29286",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","27312",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","24256",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","29822",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","33116",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","30413",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","33965",,,,,,,"fee schedule","24256","35471",
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","40024",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","61319",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","51814",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","52812",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","47947",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","44830",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","58219",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","53307",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","53433",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","61319",,,,,,,"fee schedule","40024","61319",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","229.25","229.25","229.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","32111",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","30836",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","21739",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","28195",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","23369",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","21739",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","27861",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","25820",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","33531",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","29606",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","28290",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","32111",,,,,,,"fee schedule","21739","33531",
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","200","200","200","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","38066",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","44208",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","34566",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","41973",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","28850",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","32319",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","38424",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","37347",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","38518",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","44208",,,,,,,"fee schedule","28850","44208",
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","37107","37107","37107","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","25946",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","27579",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","20900",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","22954",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29809",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24890",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","14952",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","14952",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","25920",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","25062",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","25946",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","24895",,,,,,,"fee schedule","14952","29809",
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","25189","25189","25189","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","28868","28868","28868","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","52147",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","34035",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","44911",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","44061",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","38124",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","40774",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","49510",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","45330",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","45438",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","52147",,,,,,,"fee schedule","34035","52147",
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","28461",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","24051",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","18578",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","24514",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","24742",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","27022",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","20808",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","22254",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","24804",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","28461",,,,,,,"fee schedule","18578","28461",
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","19276","19276","19276","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","24329",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","30068",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","18611",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","32102",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","34537",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28747",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","26594",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","18611",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","29816",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","29037",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","28405",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","30068",,,,,,,"fee schedule","18611","34537",
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","10292","10292","10292","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","75","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","31046",,,,,,,"fee schedule","31046","40319",
"Description Not Available","75","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","36229",,,,,,,"fee schedule","31046","40319",
"Description Not Available","75","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33204",,,,,,,"fee schedule","31046","40319",
"Description Not Available","75","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40319",,,,,,,"fee schedule","31046","40319",
"Description Not Available","75","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","36041",,,,,,,"fee schedule","31046","40319",
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]","72285","72285","72285","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","42627",,,,,,,"fee schedule","31163","42627",
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40472",,,,,,,"fee schedule","31163","42627",
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","36358",,,,,,,"fee schedule","31163","42627",
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33329",,,,,,,"fee schedule","31163","42627",
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","31163",,,,,,,"fee schedule","31163","42627",
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","36170",,,,,,,"fee schedule","31163","42627",
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","37492",,,,,,,"fee schedule","31163","42627",
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","42627",,,,,,,"fee schedule","31163","42627",
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","35090",,,,,,,"fee schedule","27020","35090",
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","28985",,,,,,,"fee schedule","27020","35090",
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","27020",,,,,,,"fee schedule","27020","35090",
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","29610",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","28843",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23811",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","30921",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","25697",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","21129",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","21129",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","25996",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","29610",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","26514",,,,,,,"fee schedule","21129","30921",
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","76","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","27490",,,,,,,"fee schedule","22731","33285",
"Description Not Available","76","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","30979",,,,,,,"fee schedule","22731","33285",
"Description Not Available","76","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","25630",,,,,,,"fee schedule","22731","33285",
"Description Not Available","76","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","22731",,,,,,,"fee schedule","22731","33285",
"Description Not Available","76","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","33285",,,,,,,"fee schedule","22731","33285",
"Description Not Available","76","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","22731",,,,,,,"fee schedule","22731","33285",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","25689",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","22123",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","21704",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","18780",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","16766",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","20086",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","24391",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","22332",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","22382",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","25689",,,,,,,"fee schedule","16766","25689",
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","17272.25","17272.25","17272.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","18099",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","17183",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","15590",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","11816",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","13233",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","14152",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","15739",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","15299",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","15775",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","18099",,,,,,,"fee schedule","11816","18099",
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","15198","15198","15198","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","40479.25","32867.52","50889","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","43592.65","28797.69","44766","14","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","26467.56","26467.56","26467.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","40454","40454","40454","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","47860.96","21820.58","52662","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","8619.48","8619.48","8619.48","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","28893","25422.28","45984","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","19276","19276","19276","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","48720","48720","48720","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","17909.1","17909.1","49025.95","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","9638","9638","86333.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","103489","103489","103489","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","20963","20963","20963","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]","13434","13434","13434","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","4123.06","4123.06","4123.06","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","27420.4","27420.4","27420.4","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","44766","44766","44766","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","52498","52498","52498","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","52662","52662","52662","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","31062","31062","31062","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","26166","26166","26166","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","32129","32129","32129","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","33695","33695","33695","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","24431","24431","24431","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","50889","50889","50889","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","20889","20889","50889","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","14196.69","14196.69","14196.69","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","44766","43766","44766","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","52662","52662","52662","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","45984","45984","45984","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","50889","44709.27","50889","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","50889","42407.5","50889","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","11251.21","11251.21","11251.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","44766","1020.46","44766","19","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","51717.19","51115.77","52498","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","40454","40454","40454","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","43271","43271","43271","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","52662","47145.7","52662","17","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]","46776","46776","46776","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","7930.86","7930.86","7930.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","45984","45984","45984","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","31062","31062","31062","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","31062","31062","31062","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","11251.21","11251.21","11251.21","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","26671.49","25810.25","27166","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","26483","3212.9","32129","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","24758","24758","24758","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","26483","26483","26483","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","33695","2354.87","33695","16","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","6285.35","6285.35","7930.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","6285.35","6285.35","6285.35","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","27851","27851","27851","14","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","5250.73","5250.73","5250.73","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","261392","261392","261392","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","401058.86","401058.86","401058.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Prematurity With Major Problems","791","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1568.86","1568.86","1568.86","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","7726.05","7726.05","7726.05","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","11201","11201","11201","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","21552.39","21552.39","21552.39","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","2047.22","2035.76","2047.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","7056","6384.68","11719.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1568.86","1143.58","4315.92","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","5026.98","5026.98","5026.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Neonate With Other Significant Problems","794","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","5793.27","5793.27","5793.27","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","2035.76","11.46","2047.22","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","6426.82","5910.68","10052.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1143.58","1143.58","1143.58","18","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","1137.3","1137.3","1137.3","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","24501","24501","24501","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Normal Newborn","795","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","11334.77","11334.77","11334.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","44766","44766","44766","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","6547.44","6547.44","6547.44","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","54023.04","54023.04","54023.04","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","55087",,,,,,,"fee schedule","49768","66877",
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","66877",,,,,,,"fee schedule","49768","66877",
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","49768",,,,,,,"fee schedule","49768","66877",
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","36034",,,,,,,"fee schedule","36034","48422",
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","48422",,,,,,,"fee schedule","36034","48422",
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","39884",,,,,,,"fee schedule","36034","48422",
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","31062","31062","31062","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","7821.32","7821.32","7821.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","26385.84","25497.73","27166","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","32129","32129","32129","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","30766.58","28020","33695","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","6164.19","6164.19","6164.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","27851","27851","27851","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","31062","31062","31062","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","31062","20708","31062","17","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","7821.32","7821.32","7821.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","15821.8","15821.8","15821.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","27166","26166","27166","22","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","32129","654","32129","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","24758","24758","24758","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","200","200","200","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","33695","28465.72","33695","11","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","4369.08","4369.08","6164.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","27851","27851","27851","12","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","20033","20033","20033","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","20033","6677.67","20033","30","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","6738.07","6738.07","6738.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","17505.75","14387.5","17817","66","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","12630.42","12630.42","12980.46","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","20791","18814.08","20791","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","16022","16022","16022","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]","200","200","200","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","22009","20377.11","22009","35","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","3763.3","3763.3","6164.19","15","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","18060","18060","18060","35","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","93936",,,,,,,"fee schedule","72334","93936",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","72334",,,,,,,"fee schedule","72334","93936",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","77593",,,,,,,"fee schedule","72334","93936",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","47004.52","47004.52","47004.52","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","42222",,,,,,,"fee schedule","39362","51116",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","39362",,,,,,,"fee schedule","39362","51116",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","51116",,,,,,,"fee schedule","39362","51116",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","14851.88","14851.88","14851.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","17551",,,,,,,"fee schedule","17551","22794",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","18827",,,,,,,"fee schedule","17551","22794",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","22794",,,,,,,"fee schedule","17551","22794",
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","10059.77","10059.77","10059.77","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","9638","9638","9638","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","18093.8","18093.8","18093.8","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Coagulation Disorders","813","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","10292","10292","10292","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","28893","28893","28893","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","9956.2","9956.2","9956.2","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","20584","20584","20584","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","96570.88","96570.88","96570.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","28798","28798","28798","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","24037","24037","24037","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","55517","55517","55517","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","28893","28893","28893","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","191253.38","191253.38","191253.38","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","9638","9638","9638","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","82316","82316","82316","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","135621.19","135621.19","135621.19","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","77048","77048","77048","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","6781.89","6781.89","6781.89","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","28037.56","28037.56","28037.56","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","13740.6","13740.6","13740.6","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","4734.66","4734.66","4734.66","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","22634.91","22634.91","32351.92","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","12276.82","12276.82","12276.82","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","23","23","23","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","19262","19262","19262","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","10376","6831","47747.42","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","380.1","380.1","380.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","24214.47","24214.47","24214.47","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","23271","23271","23271","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","906.75","906.75","906.75","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","3788.02","3788.02","3788.02","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","450952","450952","450952","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","63129.42","63129.42","63129.42","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","84","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","24652",,,,,,,"fee schedule","22272","29928",
"Description Not Available","84","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","22272",,,,,,,"fee schedule","22272","29928",
"Description Not Available","84","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","29928",,,,,,,"fee schedule","22272","29928",
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","29125.78","29125.78","29125.78","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","39862.18","38836.59","56769.32","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","22302","22302","22302","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","15198","15198","15198","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","85365.61","85365.61","85365.61","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","35492",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","23647",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","31394",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","34456",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","33841",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","40772",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","23647",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","34278",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","34049",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","35492",,,,,,,"fee schedule","23647","40772",
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","45676",,,,,,,"fee schedule","42580","55297",
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","42580",,,,,,,"fee schedule","42580","55297",
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","55297",,,,,,,"fee schedule","42580","55297",
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","57317.61","57317.61","57317.61","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","10292","10292","10292","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","57063.44","57063.44","135753.17","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","189396","189396","189396","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","45804.37","45804.37","45804.37","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","164476.78","164476.78","164476.78","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","38524","38524","38524","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","27417",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","37447",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","32423",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","26698",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","36176",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","39106",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","26698",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","30112",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","36474",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","32877",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","33537",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","37447",,,,,,,"fee schedule","26698","39106",
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","20897.54","20897.54","20897.54","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","28893","28893","28893","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","31072",,,,,,,"fee schedule","23123","31072",
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","25593",,,,,,,"fee schedule","23123","31072",
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","23123",,,,,,,"fee schedule","23123","31072",
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","87","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","23507",,,,,,,"fee schedule","21239","28540",
"Description Not Available","87","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","28540",,,,,,,"fee schedule","21239","28540",
"Description Not Available","87","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","21239",,,,,,,"fee schedule","21239","28540",
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","160889.16","160889.16","160889.16","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","100999.38","100999.38","100999.38","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]","46326","46326","46326","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","40929","20834.82","40929","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]","43656","43656","43656","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","50721.08","47954.2","255401.78","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","10292","10292","10292","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","31629.53","150","58700.07","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","12558.34","12558.34","12558.34","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","24315.43","24315.43","24315.43","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","28893","28893","28893","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","22836.53","22836.53","22836.53","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","14824.73","14824.73","14824.73","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","48190","48190","48190","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","25434","25434","30876","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","31724","31724","31724","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","17845.93","17845.93","17845.93","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","26996","26996","26996","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","24631.9","24631.9","24631.9","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]","48705.01","48705.01","48705.01","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","100971",,,,,,,"fee schedule","77752","100971",
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","83404",,,,,,,"fee schedule","77752","100971",
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","77752",,,,,,,"fee schedule","77752","100971",
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO","18466",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO","19159",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","15405",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","20006",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual","13995",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","16585",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual","13652",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO","18619",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO","13652",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO","16820",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO","17158",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO","19159",,,,,,,"fee schedule","13652","20006",
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","15296.09","15296.09","15296.09","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","47056","47056","47056","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","9266.17","9266.17","9266.17","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","71331.39","71331.39","71331.39","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]","4819","4819","4819","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","47108.88","47108.88","47108.88","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","3838.55","3838.55","3838.55","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","8507.37","8507.37","8507.37","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","48190","48190","48190","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21218.85","21218.85","21218.85","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","21744","21744","21744","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","153741","153741","153741","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","21218.72","21218.72","21218.72","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","94","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","95973",,,,,,,"fee schedule","95973","128968",
"Description Not Available","94","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","106228",,,,,,,"fee schedule","95973","128968",
"Description Not Available","94","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","128968",,,,,,,"fee schedule","95973","128968",
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","11915.98","11915.98","11915.98","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","95","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","66146",,,,,,,"fee schedule","66146","88886",
"Description Not Available","95","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","88886",,,,,,,"fee schedule","66146","88886",
"Description Not Available","95","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","73214",,,,,,,"fee schedule","66146","88886",
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","208.05","208.05","208.05","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","198.03","198.03","198.03","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]","94924.44","94924.44","94924.44","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Other Factors Influencing Health Status","951","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","203.97","203.97","203.97","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","96","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","61541",,,,,,,"fee schedule","61541","82696",
"Description Not Available","96","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","68115",,,,,,,"fee schedule","61541","82696",
"Description Not Available","96","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","82696",,,,,,,"fee schedule","61541","82696",
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","97","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","150286",,,,,,,"fee schedule","150286","195166",
"Description Not Available","97","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","161210",,,,,,,"fee schedule","150286","195166",
"Description Not Available","97","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","195166",,,,,,,"fee schedule","150286","195166",
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]","32794.1","32794.1","32794.1","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","172788","172788","172788","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]","43089.11","43089.11","43089.11","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","37581.25","37581.25","37581.25","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Description Not Available","98","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO","73560",,,,,,,"fee schedule","56644","73560",
"Description Not Available","98","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS","60762",,,,,,,"fee schedule","56644","73560",
"Description Not Available","98","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual","56644",,,,,,,"fee schedule","56644","73560",
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]","128059","128059","128059","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]","19276","19276","19276","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]","1347.53","1347.53","1347.53","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO / PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Aetna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 627656 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10687] [Surgical-Per Diem: 10687] [ICU-Per Diem: 26543] [CCU-Per Diem: 26543] [Step Down-Per Diem: 15095] [C-Section-Case Rate: 31995] [Normal Vaginal Delivery-Case Rate: 20635] [Normal Newborn-Case Rate: 20635] [Nursery  Level 1- Boarder-Per Diem: 3151] [Nursery  Level 2-Per Diem: 10717] [Nursery  Level 3-Per Diem: 15488] [Nursery  Level 4-NICU-Per Diem: 35945] [Alcohol/ Chemical Dependency-Per Diem: 6389] [Psych-Per Diem: 3762] [Rehab-Per Diem: 9301] [SNF-Per Diem: 3192] [ECT (%BC): 3192] [Bariatric Surgery-Case Rate: 61721] [Trauma  (%BC): 76]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","HMO/PPO",,,"[Stop Loss: Charge Threshold: 738409] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10249] [Surgical-Per Diem: 10249] [ICU-Per Diem: 25559] [CCU-Per Diem: 25559] [Step Down-Per Diem: 15311] [Normal Newborn-Per Diem: 2755] [Nursery  Level 2-Per Diem: 10669] [Nursery  Level 3-Per Diem: 15476] [Nursery  Level 4-NICU-Per Diem: 35879] [Alcohol/ Chemical Dependency-Per Diem: 6970] [Rehab-Per Diem: 3030] [SNF-Per Diem: 3478] [ECT (%BC): 3478]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Individual",,,"[Stop Loss: Charge Threshold: 738409 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 7766] [Surgical-Per Diem: 7766] [ICU-Per Diem: 19370] [CCU-Per Diem: 19370] [Step Down-Per Diem: 11606] [Normal Newborn-Per Diem: 2090] [Nursery  Level 2-Per Diem: 8087] [Nursery  Level 3-Per Diem: 11729] [Nursery  Level 4-NICU-Per Diem: 27192] [Alcohol/ Chemical Dependency-Per Diem: 5283] [Rehab-Per Diem: 2296] [SNF-Per Diem: 2635] [ECT (%BC): 2635]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medi-Cal",,,"[Lesser Than Charges paid at %: 100.00] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement] [Alcohol/ Chemical Dependency-Per Diem: 3098] [SNF-Per Diem: 1849] [ECT (%BC): 1849] [Trauma  (%BC): 60]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Anthem","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","HMO/PPO",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10628] [Surgical-Per Diem: 10628] [ICU-Per Diem: 26259] [CCU-Per Diem: 26259] [Step Down-Per Diem: 15765] [C-Section-Case Rate: 33176] [Normal Vaginal Delivery-Case Rate: 21469] [Normal Newborn-Per Diem: 3209] [Nursery  Level 1- Boarder-Per Diem: 3209] [Nursery  Level 2-Per Diem: 10988] [Nursery  Level 3-Per Diem: 15859] [Nursery  Level 4-NICU-Per Diem: 36864] [Alcohol/ Chemical Dependency-Per Diem: 7548] [Psych-Per Diem: 4294] [Rehab-Per Diem: 4030] [SNF-Per Diem: 3649] [Bariatric Surgery-Case Rate: 27145] [Trauma  (%BC): 76.5]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Individual",,,"[Stop Loss: Charge Threshold: 679530 | Threshold Total (% BC): 44] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8190] [Surgical-Per Diem: 8190] [ICU-Per Diem: 20235] [CCU-Per Diem: 20235] [Step Down-Per Diem: 12148] [C-Section-Case Rate: 25565] [Normal Vaginal Delivery-Case Rate: 16544] [Normal Newborn-Per Diem: 2473] [Nursery  Level 1- Boarder-Per Diem: 2473] [Nursery  Level 2-Per Diem: 8467] [Nursery  Level 3-Per Diem: 12220] [Nursery  Level 4-NICU-Per Diem: 28406] [Alcohol/ Chemical Dependency-Per Diem: 5817] [Psych-Per Diem: 3307] [Rehab-Per Diem: 3107] [SNF-Per Diem: 2813] [Bariatric Surgery-Case Rate: 20918] [Trauma  (%BC): 75.7]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Blue Shield","SFHSS",,,"[Stop Loss: Charge Threshold: 666344 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 8754] [Surgical-Per Diem: 8754] [ICU-Per Diem: 21645] [CCU-Per Diem: 21645] [Step Down-Per Diem: 12995] [C-Section-Case Rate: 27346] [Normal Vaginal Delivery-Case Rate: 17695] [Normal Newborn-Per Diem: 2646] [Nursery  Level 1- Boarder-Per Diem: 2646] [Nursery  Level 2-Per Diem: 9593] [Nursery  Level 3-Per Diem: 13847] [Nursery  Level 4-NICU-Per Diem: 32185] [Alcohol/ Chemical Dependency-Per Diem: 6206] [Psych-Per Diem: 3536] [Rehab-Per Diem: 3325] [SNF-Per Diem: 3004] [Bariatric Surgery-Case Rate: 22377] [Trauma  (%BC): 76.4]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","HMO",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Chinese Community Health Plan","Individual",,,"[Stop Loss: Charge Threshold: 674576 | Threshold Total (% BC): 53] [MSDRG Base Rate: See Fee Schedule] [Medical-Per Diem: 7573] [Surgical-Per Diem: 7573] [ICU-Per Diem: 18726] [CCU-Per Diem: 18726] [Step Down-Per Diem: 11236] [C-Section-Case Rate: 17183] [Normal Vaginal Delivery-Case Rate: 11114] [Nursery  Level 1- Boarder-Per Diem: 2287] [Nursery  Level 2-Per Diem: 8579] [Nursery  Level 3-Per Diem: 12390] [Nursery  Level 4-NICU-Per Diem: 28789] [Alcohol/ Chemical Dependency-Per Diem: 5195] [Psych-Per Diem: 2875] [Rehab-Per Diem: 7443] [SNF-Per Diem: 2449] [Bariatric Surgery-Case Rate: 45629] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Transplants (%BC): 69]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Cigna","HMO/PPO",,,"[Stop Loss: Charge Threshold: 546960 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 11258] [Surgical-Per Diem: 11258] [ICU-Per Diem: 27953] [CCU-Per Diem: 27953] [Step Down-Per Diem: 16817] [C-Section-Case Rate: 34892] [Normal Vaginal Delivery-Case Rate: 22790] [Nursery  Level 1- Boarder-Per Diem: 3652] [Nursery  Level 2-Per Diem: 11599] [Nursery  Level 3-Per Diem: 16766] [Nursery  Level 4-NICU-Per Diem: 36935] [Rehab-Per Diem: 9776] [SNF-Per Diem: 3511] [ECT (%BC): 3511] [Bariatric Surgery-Case Rate: 55942] [Trauma  (%BC): 85]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","HMO/PPO",,,"[Stop Loss: Charge Threshold: 731675 | Threshold Total (% BC): 55] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 9422] [Surgical-Per Diem: 9422] [ICU-Per Diem: 23431] [CCU-Per Diem: 23431] [Step Down-Per Diem: 14133] [C-Section-Case Rate: 29804] [Normal Vaginal Delivery-Case Rate: 19386] [Nursery  Level 1- Boarder-Per Diem: 3058] [Nursery  Level 2-Per Diem: 10916] [Nursery  Level 3-Per Diem: 15757] [Nursery  Level 4-NICU-Per Diem: 36574] [Alcohol/ Chemical Dependency-Per Diem: 9422] [Rehab-Per Diem: 9460] [SNF-Per Diem: 3624] [ECT (%BC): 3624] [Cardiac Cath-Case Rate: Fee Schedule] [Cardiac Surgery-Case Rate: Fee Schedule] [Trauma  (%BC): 77]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Net","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]","122514.68","122514.68","122514.68","1 through 10","other",,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"San Francisco Health Plan","Medi-Cal",,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.hca.wa.gov/billers-providers-partners/prior-authorization-claims-and-billing/hospital-reimbursement]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","HMO / PPO",,,"[Stop Loss: Charge Threshold: 802232 | Threshold Total (% BC): 55] [Lesser Than Charges paid at %: 100.00] [MSDRG Base Rate: Fee Schedule] [Medical-Per Diem: 10088] [Surgical-Per Diem: 10088] [ICU-Per Diem: 25093] [Step Down-Per Diem: 15096] [C-Section-Case Rate: 29174] [Normal Vaginal Delivery-Case Rate: 18918] [Normal Newborn-Per Diem: 2844] [Nursery  Level 1- Boarder-Per Diem: 2844] [Nursery  Level 2-Per Diem: 10693] [Nursery  Level 3-Per Diem: 14972] [Nursery  Level 4-NICU-Per Diem: 34795] [Alcohol/ Chemical Dependency-Per Diem: 7829] [Psych-Per Diem: 4371] [Rehab-Per Diem: 9938] [ECT (%BC): 3663] [Bariatric Surgery-Case Rate: 24769] [Trauma  (%BC): 82]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG",,,,,,,"facility","inpatient",,,,,,"United","Medicare Adv_ HMO / PPO",,,"[MSDRG Base Rate: 100% of Medicare]",,,,"0","other",,,"No services performed during 15-month lookback period."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,"facility","both",,,"25",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Bilateral Procedure",,,,,,,,,"facility","both",,,"50",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Reduced Services",,,,,,,,,"facility","both",,,"52",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Distinct Procedural Service",,,,,,,,,"facility","both",,,"59",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System",,,,,,,,,"facility","both",,,"95",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy",,,,,,,,,"facility","both",,,"EC",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care",,,,,,,,,"facility","both",,,"GN",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care",,,,,,,,,"facility","both",,,"GO",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care",,,,,,,,,"facility","both",,,"GP",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,"facility","both",,,"GY",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Item or service expected to be denied as not reasonable and necessary",,,,,,,,,"facility","both",,,"GZ",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered intravenously",,,,,,,,,"facility","both",,,"JA",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Administered subcutaneously",,,,,,,,,"facility","both",,,"JB",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JW",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Zero drug amount discarded/not administered to any patient",,,,,,,,,"facility","both",,,"JZ",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)",,,,,,,,,"facility","both",,,"LT",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing",,,,,,,,,"facility","both",,,"PI",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital",,,,,,,,,"facility","both",,,"PN",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy",,,,,,,,,"facility","both",,,"PS",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Routine clinical service provided in a clinical research study that is in an approved clinical research study",,,,,,,,,"facility","both",,,"Q1",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Clia waived test",,,,,,,,,"facility","both",,,"QW",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery",,,,,,,,,"facility","both",,,"RI",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Modifier description not available",,,,,,,,,"facility","both",,,"RISK",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)",,,,,,,,,"facility","both",,,"RT",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Member of high risk population (use only with codes for immunization)",,,,,,,,,"facility","both",,,"SK",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Aetna","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Aetna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Anthem","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Anthem","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Anthem","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Anthem","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Blue Shield","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Blue Shield","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Blue Shield","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Blue Shield","SFHSS",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Central Health Plan","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Chinese Community Health Plan","HMO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Chinese Community Health Plan","Individual",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Cigna","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Health Net","HMO/PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Health Net","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Health Plan of San Mateo","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"Health Plan of San Mateo","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"San Francisco Health Plan","Medi-Cal",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"United","HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,"facility","both",,,"XU",,,"United","Medicare Adv_ HMO / PPO",,,,,,,,,,,"The modified price is presented in the standard charge value."